A little more than a week ago I pondered why the American College of Nurse Midwives has thrown ethics to the wind by supporting waterbirth although it has been shown to be deadly. It is one example of the way in which CNMs value their professional autonomy over scientific evidence.

Now comes another in, of all places, the Journal of Midwifery and Women’s Health. Three CNMs have written an extraordinary paper that demonstrates far more powerfully than I ever could that CNMs reject science based standards that might limit their autonomy, as if science based standards are somehow discretionary. The paper is Formulating Evidence-Based Guidelines for Certified Nurse-Midwives and Certified Midwives Attending Home Births by Cook, Avery and Frisvold.

The study was simple and straightforward:

Following a review of home birth guidelines from multiple countries, a set of home birth practices guidelines for US CNMs/CMs was drafted. Fifteen American Midwifery Certification Board, Inc. (AMCB)-certified home birth midwives who participate in the American College of Nurse-Midwives (ACNM) home birth electronic mailing list considered the use of such a document in their practices and reviewed and commented on the guidelines.

In other words, the authors compiled evidence based standards that guide the practice of homebirth midwifery in countries like the Netherlands, the UK, Australia and Canada.

The response of the CNM reviewers was horrifying:

The primary concern expressed was that an adoption of national guidelines could compromise provider autonomy.

Apparently the CNMs favored the implementation of evidence based standards for American homebirth until they saw what the evidence showed. When they learned they were not practicing in accord with international evidence based homebirth standards, they decided to ditch the standards instead of changing their practice.

That, in a word, is unethical.

What were these international standards that CNMs rejected and where did those standards come from?

Five countries with provincially or nationally promulgated home birth midwifery guidelines met these criteria: Australia, Canada, the Netherlands, New Zealand, and the United Kingdom. Published guidelines of these countries were then reviewed for common themes. The following criteria for planning a home birth emerged: determination of low-risk pregnancy, informed consent, hospital transfer if complications arise, singleton pregnancy, fetus in the cephalic presentation, no history of previous cesarean birth, and term pregnancy.

Then:

After collection, review, and summary of these international guidelines, the primary author synthesized the information into draft home birth guidelines that could be used by US CNMs/CMs. The resulting 10-page document (see Supporting Information: Appendix S1) includes recommendations about licensure, physician collaboration, hospital transports, informed consent, documentation, client screening, equipment, medications, birth assistants, routine care of the mother and newborn, and emergency care of the mother and newborn

Five different countries; agreed upon basic standards for care… rejected by the CNM reviewers.

Even the authors were shocked:

… [T]he authors were surprised that the reviewers expressed greater interest in developing and implementing national home birth midwifery guidelines prior to reviewing the proposed guidelines versus after their review…

The primary concern raised by the reviewers was whether or not guidelines would impact their autonomy. Guidelines are intended to provide best practices from which providers can meet individual client needs but also discourage providers from diverging from safe practices. The reviewers specified that the proposed guidelines might not support them if they choose to attend the home birth of a woman with a breech presentation or a twin gestation or a woman who desires a trial of labor after a previous cesarean. While CNMs/CMs attending home births may have the skill to attend such births, the safety net available in an institutional setting is advantageous and may be preferable for such births…

Indeed, the authors feel compelled to re-state the obvious requirement for ethical practice:

Although ensuring client safety may at times conflict with provider and client preferences, safety is the first priority for improving the quality of health care.

Apparently not for CNMs.

The authors note:

Fundamental to international home birth guidelines that were examined in this project is a distinction between low risk and high-risk maternity criteria. Normal birth has been defined in a joint statement by the Society of Obstetricians and Gynaecologists of Canada; the Association of Women’s Health, Obstetric, and Neonatal Nurses of Canada; the Canadian Association of Midwives; the College of Family Physicians of Canada; and the Society of Rural Physicians of Canada as spontaneous labor with a singleton fetus in a
vertex presentation at 37 to 42 weeks’ gestation after an uncomplicated pregnancy. This definition is consistent with the World Health Organization definition and the UK Maternity Care Working Party definition supported by the RCOG and RCM. (emphasis in original)

We already know that American homebirth midwives (CPMs, LMs, DEMs) lack basic professional ethics. Now comes stunning confirmation that American CNMs attending homebirths are equally ethically bankrupt.

What should American women take away from this study?

It is yet more evidence that midwives who attend homebirths (CPMs and CNMs) value their professional autonomy over whether your baby lives or dies. It is more important for them to maintain control over you (and collect a fee from you) than to accurately advise you. Moreover, the homebirth safety data from countries like the Netherlands and the UK can’t possibly apply to homebirth in the US because even homebirth CNMs refuse to follow the guidelines that govern homebirth in those countries.

Homebirth is a fringe practice. We can argue about whether it might be safe under ideal conditions, but it CANNOT be safe in the US because the midwives who attend homebirths (CPMs and CNMs) explicitly reject safety standards. And as long as they continue to do so, babies (and sometimes mothers) will continue to die preventable deaths at their hands.

Imagine if smokers blamed cancer and emphysema deaths on pulmonologists. If only those lung doctors would invent a safer tobacco cigarette many fewer people would die of lung cancer, right?

Imagine if vaccine rejectionists blamed the pertussis deaths in children who are unvaccinated on pediatricians who won’t treat unvaccinated patients. If only the parents could have taken their coughing, vomiting, whooping baby to the local pediatrician instead of the hospital ER, the chances of the baby surviving might have been increased, right?

Imagine if the survivors of people who shun conventional cancer treatments claimed that oncologists were responsible for the deaths of those who chose alternative treatments. After all, if oncologists had created chemotherapy that was gentler, the person who refused chemotherapy might have accepted it, right?

We recoil from those claims for very good reasons:

Pulmonologists have no responsibility for improving the safety of cigarettes. The people who bear the ultimate responsibility for tobacco caused lung cancer are the people who choose to smoke.

It’s not the job of pediatricians to improve the safety of vaccine refusal. The people who bear the ultimate responsibility for a vaccine preventable death are those who refused vaccines.

It is not the job of oncologists to make chemotherapy as pleasant as alternative “treatments” (although they are indeed trying to do so). The people who bear ultimate responsibility for dying a chemotherapy preventable death are the people who refuse chemotherapy.

Now tell me: whose fault is it that homebirth is not safe?

Yesterday I wrote about Elizabeth Heineman, currently publicizing a book long apologia on her son’s death at homebirth. Where does Heineman place the blame? On everyone but herself. Indeed, in an especially creative attempt to avoid responsibility for choosing homebirth, Heineman actually blames “politics.”

I believe that after decades of successful practice and no bad outcomes, Deirdre made the wrong judgment call in not referring me to a doctor once I was a week postdate. I believe that judgment call resulted in Thor’s death.

I believe the likelihood of her making the wrong judgment call was heightened by the fact that she felt under siege. I believe the warfare between the medical profession and out-of-hospital midwives made her reluctant to refer a low-risk pregnancy with no sign of trouble to a doctor …

It’s those obstetricians! They are responsible for her baby Thor’s death because they refuse to collaborate with homebirth midwives.

No, they’re not responsible for Thor’s death any more than pulmonologists are responsible for tobacco related deaths, or pediatricians are responsible for vaccine-preventable deaths or oncologists are responsible for the deaths of those who refuse chemotherapy. They are not responsible because they offer a safer alternative to the unsafe choices that people make. They are under no moral obligation to mitigate the danger of unsafer choices, beyond counseling against them.

Homebirth is the same. If you choose homebirth and your baby dies as a result, you bear responsibility.

You are not the only one who bears responsibility; there is an entire industry of natural childbirth and homebirth “professionals” feeding you lies about homebirth safety and they should be held accountable, too. But there is not a homebirth advocate alive who does not recognize that her choice is a rejection of conventional medical advice and a transgressive choice. Indeed many homebirth mothers choose homebirth precisely BECAUSE it is a rejection of conventional medical advice and a transgressive choice.

To the extent that homebirth midwives attempt to obtain informed consent, they almost always declare that in the event of disaster, they are not responsible. The consent forms often require the mothers to specifically accept responsibility for any bad outcomes. And indeed, when the inevitable tragedies occur, they turn in anger toward homebirth loss mothers who dare to expect accountability of homebirth midwives. The was NEVER part of the plan. The mother always knew that she was rejecting conventional medical advice and she is supposed to shoulder the responsibility for that decision, not those selfless “birth workers” who were merely giving her what she asked for.

When it comes to responsibility, homebirth is a game of musical chairs. There are lots of people and chairs at the beginning of the game: the midwife, the doula, the cranio-sacral therapist, all the providers of homebirth services start out with chairs. The minute a woman starts labor at home, the homebirth midwives and mothers pull out all the chairs, but one, the obstetrician’s chair. You remember the obstetrician. He or she is the one the mother ignored as not evidenced based, profit hungry, and driven to perform unnecessary C-sections just to get to his golf game. THAT obstetrician, the one the mother didn’t trust, it the ONE person she expects will save her baby and her if anything goes wrong.

The ultimate problem, though, is that American homebirth is not and can never be as safe as hospital birth. It is simply impossible because it is the hospital and the expert personnel and safety equipment that makes hospital birth safe. When you reject the safest choice, doctors are not ethically obligated to make your preferred unsafe choice safer.

When a person dies of a tobacco related illness, he or she is ultimately responsible, not the doctors who didn’t make cigarettes safer.

When a baby dies of a vaccine preventable illness after a parent rejects vaccines, the parent is responsible, not the pediatrician who advised against it and refused to care for the child thereafter.

When a person dies of cancer after refusing cancer treatment, he or she is responsible, not the oncologist who advised against it and refused to administer the alternative “treatment.”

And when a baby dies at homebirth, the mother is responsible, not the obstetrician who advised against it and refused to collaborate with a midwife he did not trust.

Homebirth mothers are very happy to claim credit when they dodge a bullet by refusing conventional care. If they are willing to claim credit, they are responsible when things go wrong. Homebirth is INHERENTLY unsafe and American homebirth will NEVER be as safe as hospital birth. Obstetricians are not responsible for making unsafe choices safer. Mothers are responsible for making unsafe choices.

Heineman’s midwife deliberately chose to ignore standard obstetrical practice, not because she didn’t know any better, but because she thought she could get away with it. After all, she had gotten away with it in the past.

Politics did not kill baby Thor. His mother’s decision led to his death. Had she chosen to accept conventional obstetrical care, Thor would almost certainly be alive to day. Heineman bears the ultimate responsibility, and her efforts to avoid that responsibility, while understandable, are shameful nonetheless.

American homebirth advocacy is filled with mistruths, half truths and outright lies.

The biggest lie, of course, is that homebirth is safe. It’s not. American homebirth has a death rate 2-9X higher than comparable risk hospital birth, depending on attendant.

The second biggest lie is that homebirth advocates take responsibility for their decisions. Yes, they are happy to take credit for decisions that ended up with a live mother and a live baby. When it comes to bad decisions, however, if their baby was one of the many babies who die at homebirth, they shed responsibility like water off a duck’s back. It was everyone’s fault but their own.

Some women are more creative than others in avoiding responsibility. Elizabeth Heineman, currently promoting her new book Ghostbelly, the story of her son Thor’s death at homebirth is more creative than most. Heinemen “educated” herself and purposefully chose homebirth. Thor is dead as a result. Who does she blame? Why, politics, of course:

I believe that my nurse-midwife Deirdre is an excellent practitioner. I believe her hundreds of successful deliveries and the intense loyalty of her clientele demonstrate that she provides an important service. I believe her practice of non-invasive birthing for low-risk preg­nancies contributes to a necessary movement toward more sen­sitive forms of reproductive health care.

I believe that after decades of successful practice and no bad outcomes, Deirdre made the wrong judgment call in not referring me to a doctor once I was a week postdate. I believe that judgment call resulted in Thor’s death.

I believe the likelihood of her making the wrong judgment call was heightened by the fact that she felt under siege. I believe the warfare between the medical profession and out-of-hospital midwives made her reluctant to refer a low-risk pregnancy with no sign of trouble to a doctor…

In other words, it isn’t Deidre’s fault; and it certainly isn’t Heineman’s fault. But Heinemen is wrong. I understand that the impulse to denial is monumental in a case where your baby dies because of the decision that you made. But if you are going to elevate your denial to a book length plea to be absolved of responsibility, other people are going to offer different interpretations.

Here’s what I believe:

I believe that Elizabeth Heineman made the choice to deliver at home, far from emergency equipment and personnel. I believe that Heineman chose to ignore standard medical advice of obstetricians. I believe that in choosing a homebirth midwife, Heineman chose a practitioner who valued her personal autonomy above all else, and, as a result, let a baby die. Therefore, I believe that Thor died from his mother’s desire to have a certain kind of “birth experience” and that politics had absolutely nothing to do with it.

Saying that Heineman bears responsibility for Thor’s death at homebirth is not incompatible with feeling sorry for her loss. It’s no different than grieving for a child who went through the windshield and died because her mother didn’t buckle her into a carseat. That mother is no doubt devastated, and no feeling person can failed to be moved by that devastation, but that doesn’t change the fact that the mother, through her action or inaction, is ultimately responsible for the death.

Heineman’s description of the proximate cause of Thor’s death is both elegant and haunting:

I believe that Thor died in excruciating pain. His brain, deprived of oxygen, each cell suffocating, withering into itself, crumpling, collapsing, but still struggling, alerting the nerves that something was terribly wrong. The nerves suddenly plunged into burning acid, receiving the frantic message, send­ing that information in a useless loop back to the very brain that was under siege. The brain screaming in increasing des­peration to the lungs that they should try something, anything. The lungs naively expanding, opening, to pull in relief, to pull in the cool air whose oxygen molecules it will quickly trans­mit to the bluish blood, re-reddening it, re-energizing it, so the blood can rush to the brain, restore it. The lungs instead getting meconium-filled amniotic fluid, choking the blood by transmitting precisely nothing, the blood by now dead but still pumped by the heart that hasn’t yet learned that it is all over, the heart sending the useless blood to the brain cells now wrung dry as they complete the act of withering, crumpling, collaps­ing …

And, to her credit, she does acknowledge one of the real reasons for Thor’s preventable death:

…I believe her most fundamental reason for not referring me to a doctor was much simpler: in her evaluation, it wasn’t medically necessary.

In other words, Deirdre was wrong to ignore the risk factors in Heineman’s history, but Heineman still tries to absolve her:

I believe the likelihood of Deirdre’s making a mistake was heightened by her professional isolation. I believe that isolation reduced the opportunity for informal, day-to-day talk with colleagues to remind her of risk factors that rarely come into play but which can be critical, like the dramatically higher incidence of stillbirth for women over 40 starting at 41 weeks’ gestation.”

But again Heineman has it wrong. I believe that the likelihood, indeed the near certainty of Deirdre’s ultimately making a fatal mistake, was heightened by her desire for professional autonomy. You don’t need “informal, day-to-day talk with colleagues” to understand the difference between high risk and low risk and act accordingly.

What really killed Thor?

I believe that natural childbirth and homebirth advocates (including some midwives) are perpetuating a series of big lies: that childbirth is inherently safe when the truth is that it is inherently dangerous; that childbirth without interventions is “healthier” when the truth is that it is riskier; that birth is a piece of performance art when the truth is that women have little or no control over what happens during labor; that women should judge themselves by whether they can give a specific birth performance of unmedicated vaginal birth refusing any and all interventions along the way when the truth is that how the baby is born is irrelevant, what matter most is that it is born safely.

I believe that these big lies are being perpetuated by an industry that profit from them: natural childbirth lobbying organizations like Lamaze International and the Childbirth Connection; an army of homebirth midwives, doulas and childbirth educators who would have little if any business if it weren’t for the disinformation campaign of natural childbirth: and a group of women who believe that ignoring medical authority is a demonstration of their “education” when it is nothing more than a sign of their gullibility.

I believe that babies die when celebrities with no medical knowledge like Ricki Lake evangelize and profit from their endorsement of quackery. I believe that babies die when midwives value professional autonomy over common sense. I believe that babies die when mothers locate the center of their worth in their vaginas and the transit of their progeny through them, rather than in their brains that have the power to prevent the deaths inherent to childbirth.

Simply put, I believe that babies die when their mothers choose homebirth.

And I believe that babies will continue to die preventable deaths at homebirth as long as women like Heineman refuse to take responsbility for those deaths.

It’s often an “aha” moment for women when they realize that birth is an industry.

I’m not talking about hospital birth. While that, too, is a money making proposition, no obstetrician is afraid of running out of patients. For better or worse, pregnant women need obstetricians, will always need obstetricians, and obstetricians have no need to convince women to give birth in hospitals since 99% already do so. Obstetricians are not afraid of losing business to “birth workers.”

Moreover, a substantial proportion of obstetricians are salaried or paid by insurance companies that offer no premium for extra services. There is no incentive to do any more than what he or she thinks is necessary to ensure a healthy baby to a healthy mother.

No, I’m talking about “Big Birth,” the industry of birth workers (doulas, childbirth educators, and midwives to some extent). They sell services, books, products and courses. No one actually needs any of those books and products; they are entirely discretionary. Therefore, the entire industry of Big Birth depends on convincing women that they need these books and services. Although many women don’t realize it, advocates of natural childbirth (and virtually all “birth workers” are advocates of natural childbirth) must be engaged in full time marketing in order to make a living.

That marketing involves two major prongs: convincing women they need what birth workers are selling, and warning women that obstetricians are not to be trusted.

What is Big Birth selling?

They are selling their personal view of the ideal birth.

It is important for women to understand that natural childbirth is one-size-fits-all approach. It doesn’t matter who you are, what your medical problems are, what your specific fears and concerns are, what you think is the ideal birth for you; all of that is irrelevant. Big Birth must convince you that unmedicated vaginal birth is what you really want and need.

There are important obstacles in the way. The first is pretty obvious: hours of agonizing labor pain. Ever since the discovery of chloroform for easing labor pain, women have avidly adopted analgesia in childbirth. Indeed, in the early years of the 20th Century, pain relief in labor was recognized by women’s groups in nearly all industrialized countries as a fundamental right. All women were seen as entitled to pain relief in labor regardless of their ability to pay for it, just like all women were entitled to anesthesia during surgery regardless of their ability to pay for that.

Because childbirth is inherently agonizing (it so impressed the writers of the Bible that the only way they could explain it was as a divine curse) and because human beings natural wish to avoid agonizing pain, it’s been an uphill battle for Big Birth, but they finally hit on a double barreled solution. The first part is to convince women that epidurals, the only truly effective method for abolishing the pain of childbirth, are dangerous for their babies; that’s nothing more than a lie, but as I explained yesterday, lying is central to natural childbirth advocacy. And although Big Birth does not lie outright about the maternal risks of epidurals, they grossly inflate the risks and minimize the benefits.

The second barrel is the imperative to convince women that the “ideal” birth as envisioned by birth workers (an unmedicated vaginal delivery) is somehow superior to other ways of giving birth and that women who “achieve” an unmedicated vaginal birth are somehow superior to women who don’t. Why would a woman buy any of the services and products sold by birth workers if they weren’t convinced that they needed them? Obviously they wouldn’t, so it is absolutely critical for Big Birth to convince women that there is a “best way” to give birth and they can help you achieve it.

The other important obstacle to Big Birth is that they don’t have the knowledge and skills to offer life saving services. The marketing solution to that is simple: just convince women that birth is so safe that almost no one ever needs those life saving services. It’s a lie, but, once again, a lie is no problem for the marketing gurus of Big Birth.

To summarize, the first part of the Big Birth marketing strategy is to convince women that unmedicated vaginal birth is “ideal,” that pain relief is dangerous, and that birth is so safe that almost no one needs the interventions recommended by obstetricians.

The second major prong in Big Birth’s marketing strategy is to create distrust of obstetricians. Women need obstetricians. They don’t need birth workers, so thy must be convinced that obstetricians are out to harm them and that only birth workers can prevent that harm. That, too, is a lie, but in Big Birth the ends (profit and autonomy for birth workers) always justifies the means. Most of the claims of Big Birth are ludicrous on their face and no one would believe them of other doctors, but it is a testament to the marketing genius of Big Birth that they have managed to convince a great number of women that the people who devote their lives to caring for pregnant women and their babies (obstetricians, obstetric anesthesiologists, perinatologists and neonatologists) actually want to harm women and babies. Or, equally ludicrous, the idea that obstetricians don’t follow scientific evidence while “birth workers” do. Obstetricians don’t merely follow scientific evidence, they are the ones who create it. Birth workers, on the other hands, follow their hearts and prejudices, with their own autonomy as their only fixed lodestar. They simply make stuff up and then pretend that it is true.

Case in point, Barbara Harper, the doyenne of American waterbirth, and basically a buffoon when it comes to neonatal physiology, is revered in the world of Big Birth as an “expert” on waterbirth. She just makes it up as she goes along and major childbirth organizations from Lamaze, to the American College of Nurse Midwives throw ethics and intelligence to the wind to back her.

Indeed waterbirth is an outstanding illustration of the marketing tactics of Big Birth.

Whatever you want to say about waterbirth, no one can deny it is unnatural since no primates, let alone human beings, give birth in water. But for Big Birth the truth is irrelevant and waterbirth is marketed as “natural” pain relief.

Waterbirth was never tested before birth workers implemented it as a “treatment.”

Point out to midwives and other birth workers that waterbirth has deadly iatrogenic complications ranging from drowning to tearing off the umbilical cord while lifting the baby out of the birth pool, and midwives and birth workers won’t even bother to investigate the reports before dismissing them out of hand.

As Dr. Clay Jones notes in today’s post on Science Based Medicine, An Update on Water Immersion During Labor and Delivery:

A fine example of complementary and alternative reality in regards to labor and delivery can be found at Waterbirth International, which is run by >Barbara Harper, a nurse who preaches the benefits of waterbirthing all over the world and who is a proud proponent of rebirthing-breathwork. Rebirthing-breathwork is the concept that suppressed negative emotions can be healed by reliving one’s birth…and breathing a lot. Also there is something in there about cells having feelings. Harper gets the last word in the NPR article:

“I think this is backlash from the gaining popularity of water birth,” says Barbara Harper, founder of Waterbirth International, an advocacy organization…One thing that happens in a water birth, you as the attending physician pretty much have to stand there with your hands in your pockets and let it happen without your participation. That is pretty scary to a physician-oriented institution.”

How’s that for a straw man? Medical experts are apparently only skeptical of waterbirth because we don’t get to participate, which I have little doubt is code for “we don’t like it cause we don’t get paid.” I wonder if she works for free.

I believe that most rational people, even those with no medical experience, intuitively understand that delivering a baby into a body of water, even a sterile one, would be inherently risky. Human newborns, as with all other primates (take that Discovery Institute) breathe almost immediately upon arrival into this world. This helps to initiate a chain of events that assists the neonate in transitioning from fetal to adult circulatory patterns, and there are millions of years of evolutionary momentum behind this process. But besides being a completely unnatural act, something that usually sends proponents of pseudoscience running, there are numerous potential risks involved with giving birth underwater.

In other words lying (about the risks), denying (the complications), decrying (obstetricians) and defying (science).

Birth Big is a business. They are selling a product (unmedicated vaginal birth) that has no real benefits so they’ve had to make up the benefits. Many birth workers have no real skills, and even the best educated lack the lifesaving skills of obstetricians, so they’ve had to deny the need for such skills (Trust birth!), and demonize both the skills and the obstetricians who wield them.

There is an old Latin aphorism that comes to mind in this situation: Caveat emptor! Let the buyer beware!

That’s good advice when it comes to Big Birth. Pregnant women should be savvy consumers and understand that Big Birth is trying to sell them products and services that they don’t really need. If women want to buy them, it’s up to them, but they ought to recognize that Big Birth markets its products the exact same way that Big Business markets theirs: convincing you that you need the product, that buying the product will indicate that you are a superior person, that the competition is not to be trusted, … and that the safety standards of the competition aren’t really necessary at all and just add to the price of the product.

Would you buy a car from a manufacturer who claimed that buying their car indicates that you are a superior person, that other car manufacturers are ignorant fiends who want to hurt you, and that airbags are unnecessary because most people never crash? Probably not.

Then why would you buy a birth from a provider who claims that there is an “ideal” way to give birth, that if you do it their way you are a superior person, that the people who are experts in every kind of birth (obstetricians) are ignorant fiends who want to hurt you, and that safety features (interventions) are unnecessary because most women won’t have life threatening emergencies?

Rory Coker, professor of physics and University of Texas Austin, has written a very informative article for the website Quackwatch. The article, Distinguishing Science from Pseudoscience, was not written with the philosophy of natural childbirth in mind, but the criteria he describes make it quite clear that natural childbirth in general and homebirth midwifery in particular are nothing more than quackery.

Consider Prof. Coker’s principles in light of the recent efforts by natural childbirth and homebirth advocates to suppress the dangers of waterbirth and homebirth.

Pseudoscience displays an indifference to facts.

Waterbirth is unnatural. No primates give birth in water and everything we know about neonatal physiology tells us that babies are “designed” to be born into air. No matter. Waterbirth is touted as soothing, comforting and above all “natural.”

Pseudoscience “research” is invariably sloppy.

Of course, that’s when there is any research at all. The tenets of natural childbirth in general, and waterbirth in particular, were instituted without any efforts made to empirically validate theirs claims. The fear-tension-pain cycle? It was made up by Grantly Dick-Read and is still promoted by natural childbirth organizations in the absence of any evidence to support it. Barbara Harper has never done any research to validate her nonsensical claims about waterbirth. She probably wouldn’t know how to conduct research even if she wanted to do so

Pseudoscience begins with a hypothesis—usually one which is appealing emotionally, and spectacularly implausible—and then looks only for items which appear to support it.

That pretty much describes the entire natural childbirth literature; it is one giant festival of cherry picking, highlighting papers that appear to support it and ignoring the vast body of medical literature that does not.

Pseudoscience is indifferent to criteria of valid evidence.

At this point, natural childbirth and much of contemporary midwifery theory isn’t merely indifferent to the criteria of valid evidence, they are actively hostile to it, offering claims as disparate as randomized controlled trials are “tyrannical“; case studies of deadly waterbirth outcomes are meaningless; the series of bald-faced lies about birth certificates put forth by Melissa Cheyney, CPM and Wendy Gordon, CPM to justify their refusal to compare MANA’s homebirth death rates with US perinatal death rates; and my all time favorite: Including the Non-Rational is Sensible Midwifery.

Pseudoscience relies heavily on subjective validation.

Waterbirth advocates like The Feminist Breeder have twisted themselves into knots over this. On the one hand, case studies demonstrating catastrophic outcomes at waterbirth are derided as useless and large scale studies that show that waterbirth is poor at relieving labor pain are dismissed out of hand, while at the exact same time (without any consciousness of irony), waterbirth advocates claim that they “know” that waterbirth provides excellent pain relief because some women claim it does, and we should avoid telling women about the dangers of waterbirth until we have large scale studies of those outcomes.

TFB’s piece is downright buffoonish, implying as it does that because she can’t see bacteria in waterbirth pools, there is no bacteria.

Pseudoscience always avoids putting its claims to a meaningful test. I would add to that the fact that natural childbirth and homebirth advocacy, like all pseudoscience, strenuously avoids debating real scientists.

Natural childbirth and midwifery theorists rarely carry out quantitative research to validate their claims, and often cheerfully ignore the results of those carried about by medical researchers. They never follow up and they never acknowledge, let alone learn from, mistakes. Midwives implemented waterbirth without ever investigating whether it is safe, are desperately trying to ignore the research from neonatologists and perinatologists that shows that waterbirth has deadly dangers, and, most revealing, have absolutely no plans to investigate the deadly dangers. Waiting for a large scale midwifery study to evaluate the risk of hyponatremia, drowning or umbilical cord avulsion during waterbirth? Don’t hold your breath.

Pseudoscience often contradicts itself, even in its own terms.

See above: we don’t have to pay attention to case studies of death at waterbirth, but we “know” that waterbirth provides excellent pain relief because women (case studies) tell us so.

Pseudoscience appeals to false authority.

A high-school dropout is accepted as an expert on “normal birth” and is awarded a fake midwifery credential (CPM). Barbara Harper, an RN thoroughly ignorant of neonatal physiology and even basic chemistry, is considered an “expert” on waterbirth even though though she has never studied it in any remotely scientific way. Henci Goer, who is not an obsterician, midwife or scientist is regarded as an “expert” on the obstetric literature.

Celebrity endorsements are integral. Ricki Lake swears that homebirth is safe, so it must be. Emotional appeals are common. (“Trust birth!” “Trust your mama intuition!”) Natural childbirth/homebirth advocates are fond of conspiracies. (“Doctors just want to ruin your birth experience!” “Obstetricians recommend interventions because they make money from them!”) When confronted by inconvenient facts, they simply reply, “Doctors don’t know everything!”

Pseudoscience relies heavily on anachronistic thinking.

It’s the wisdom of our ancient foremothers! That goes twice for ideas that are obviously wrong and have been debunked by science, while pretty much sums up natural childbirth and contemporary midwifery theory.

To paraphrase Coker’s conclusion:

Characteristics of Pseudoscience

The natural childbirth/homebirth literature is aimed at the general public. There is no review, no standards, no pre-publication verification, no demand for accuracy and precision.

No physical phenomena or processes are ever found or studied. No progress is made; nothing concrete is learned.

Natural childbirth/homebirth appeals to faith and belief. It has a strong cult-like element: it tries to convert, not to convince. You are to believe in spite of the facts, not because of them. The original idea is never abandoned, whatever the evidence.

Natural childbirth/homebirth advocates often earn some or all of their living by selling products (such as doula services, books, courses, and supplements) and/or pseudoscientific services (such hypobirthing, natural childbirth courses, etc.)

Most damning of all, infant deaths (and maternal deaths) are ignored, excused, hidden, lied about, discounted, explained away, rationalized, forgotten, avoided at all costs.

It happens with waterbirth, it happens with homebirth, and it happens with deaths at the hands of contemporary midwifery theorists. Lie, deny, decry, defy. Those are the hallmarks of quackery and those are the hallmarks of natural childbirth and homebirth.

I have a riddle for you.

What would I get if I added the following?

Nuance + Compassion + Dr. Amy =

Give up?

I would get IGNORED.

That’s the real answer to the riddle posed by Kristin of Birthing Beautiful Ideas. Kristen ponders:

That’s right. Sometimes, I agree with Dr. Amy.

But I rarely agree with her delivery. Sometimes it’s rife with logical fallacies*: straw man arguments, appeals to pity, appeals to authority, ad hominem attacks. It’s often mean-spirited and shrill and condescending…

And so after I read the piece from Feminist Midwife, I wondered: what might Dr. Amy’s blog posts look like if she injected nuance, compassion, a less dogmatic form of critical thinking, and some simmering-down-now (with a teensy bit of snark, just to let off some of her steam)?

At the end of her piece, Kristen highlights a previous encounter:

You’ve been here before, and you called me a “gullible, woefully undereducated women who’s likely never read a scientific study in its entirety.” It was fun(ny). In any case, I have read plenty of scientific studies in their entirety, though surely not as many as you have. Likewise, you may have read a bit of philosophy, but likely not as much as I have. Your training gives you the upper hand when it comes to expertise in practicing medicine. Mine gives me the upper hand when it comes to expertise in all things philosophical. These different trainings and types of expertise give us somewhat different approaches when it comes to reading said scientific studies: you will arrive from a clinical background based both on your medical education and your practice of medicine, and I will arrive from a philosophical background based on an in-depth examination of the philosophy of science and on a specialization in theories of autonomy…

Kristen is referring to this post, Newsflash: you did risk your baby’s life for your own experience. Not surprisingly, I stand by everything I wrote. I will add, though, that I have more training in philosophy than Kristen might imagine. I nearly completed a master’s degree in biomedical ethics with Dan Brock when he was still at Brown (everything but the thesis). Kristen would probably be surprised to know that my interest is also in theories of autonomy, especially as they relate to reproductive decisions. That’s why I disagree so vehemently with anyone who claims that homebirth ought to be made illegal; doing so is a violation of a mother’s right to medical autonomy.

Be that as it may, I believe that Kristen’s post deserves a reply.

In a way, Kristen, you have already answered your own question. You imagined what my blog might be like if I wrote in the same style as a midwife whom you admire. You didn’t ask what my blog might be like if I wrote in the style of Dani Repp at What Ifs and Fears are Welcome or Lisa Murakami of Married to Medicine or the many bloggers like them. Both Dani and Lisa are much nicer than me! They write about the same topic as I do with more nuance and more compassion, yet you didn’t mention them. Why? Either you’ve never heard of them or they made so little impression that you forgot them.

For better or for worse, nuance and compassion don’t attract readers. Years ago I briefly tried it and it nearly killed the blog. When I started the predecessor of this blog in 2006, I got about 550 visits a day, 500 of which I bought through Google Ad Words. I haven’t paid for advertising in years. Today this blog averages 6000 visits a day on weekdays, and often thousands more. For my most popular posts I’ve gotten 5,000 visits an hour. I’m sure that you’ve already guessed that the posts with the most traffic tend to be the snarkiest.

Simply put, snark is my schtick. Don’t get me wrong: my anger over the preventable deaths of babies and the misinformation spread by natural childbirth and homebirth advocates is real. I’m no different than the pediatricians who despair over the deaths of babies as a result of the anti-vax nonsense. But I’ve chosen to take a different approach. Recently a study was published that showed efforts to educate anti-vaccine parents about the benefits of vaccination have backfired. When public health officials have tried a respectful presentation of facts to educate parents about the benefits of vaccination, those same parents ignored the facts and figured that the public health officials had something to hide. In the best case scenario, they simply ignored the public health messages.

I take a very different approach because I attribute a very different cause to both anti-vax nonsense and natural childbirth/ homebirth. Both have nothing to do with medical facts and everything to do with the tendency of contemporary parents to judge themselves and others by their willingness to defy authority. Defiance and denial are at the heart of both movements: defiance of medical “authority” and denial that bad things can really happen to them and their children that no amount of good food or breastfeeding is going to prevent.

My approach can be summed up very simply. My snarky posts about parenting decisions tend to make the exact same statement:

You think that having an unmedicated birth, refusing interventions, giving birth at home, refusing vitamin K for your newborn, etc. etc. etc marks you out as an “educated” person and a superior parent. I’m here to tell you that it marks you as an uneducated, gullible fool.

Harsh, I know, but very effective at getting attention and causing people to question what they’ve been told.

And when I write about the luminaries of the natural childbirth/ homebirth world, I deliberate tweak the love of conspiracy theories that seem so prominent among advocates:

You think that Melissa Cheyney, Lisa Barrett, Lamaze International, the Childbirth Connection, etc. etc. etc. care more about whether your child lives or dies than her obstetrician or pediatrician? Haven’t you noticed that they have a greater financial interest in conning you to buy their services, books and products than either an obstetrician or pediatrician ever could?

Most natural childbirth/homebirth advocates lack the basic knowledge to understand a nuanced argument about childbirth, but no one lacks the basic knowledge to understand the desire to profit by convincing someone to buy what you are selling.

I have a goal that I am always working toward and that is the prevention of infant and maternal deaths. Although there are a few nitwits out there who like to put my title in quotes, I find that being retired offers a great advantage in gaining trust. Everyone knows, whether they agree with me or not, that I have no skin in the game. It makes no difference to my well being or the well being of my own children whether you listen to me or not. I write for YOUR children because I care about what happens to them.

If that isn’t nuanced and compassionate, I don’t know what is.

There is a chilling story on the front page of The New York Times this morning, General Motors Misled Grieving Famiies on the Lethal Flaw:

It was nearly five years ago that any doubts were laid to rest among engineers at General Motors about a dangerous and faulty ignition switch. At a meeting on May 15, 2009, they learned that data in the black boxes of Chevrolet Cobalts confirmed a potentially fatal defect existed in hundreds of thousands of cars.

But in the months and years that followed, as a trove of internal documents and studies mounted, G.M. told the families of accident victims and other customers that it did not have enough evidence of any defect in their cars, interviews, letters and legal documents show. Last month, G.M. recalled 1.6 million Cobalts and other small cars, saying that if the switch was bumped or weighed down it could shut off the engine’s power and disable air bags.

In other words, GM absolved themselves of all responsibility for the deaths that occurred as a result of their mistake, even though they knew all along that people were dying as a direct result of the flaw.

The exact same thing is happening in the world of homebirth. Melissa Cheyney and co-authors have a commentary in this month’s issue of Birth: Issues in Perinatal Care, the “journal” published by Lamaze International. I use the term journal in quotes because a real medical journal publishes everything on a topic. Birth is nothing more than an industry mouthpiece; editors have acknowledged that they will not publish papers and reviews that don’t comport with their philosophy.

Cheyney’s piece, A Crusade Against Home Birth, is delightfully and deliberately misleading. Or it would be delightful if babies weren’t dying as a result.

The executives as GM could take lessons in obfuscation, misdirection, and outright lying from Cheyney and her fellow executives at the Midwives Alliance of North America (MANA) the trade and lobbying organization that represents non-nurse midwives (CPMs, LMs, and DEMs, laypeople who awarded themselves the designation “midwife” despite being unqualified to work as a midwife in any other industrialized country).

Cheyney and the folks at MANA are worried. Their little empire (and source of 100% of their income) is threatened by a large and growing body of evidence that homebirth at the hands of a non-nurse midwife has a hideous perinatal death rate. Indeed, their own statistics showed that homebirth with a CPM has a mortality rate 450% higher than comparable risk hospital birth, a fact that they unsuccessfully tried to lie about in another paper that Cheyney wrote.

Cheyney’s commentary is ostensibly about the Grunebaum paper that showed that homebirth increases the risk of a 5 minute Apgar score of 0 by nearly 1000%. The obfuscation starts with Cheyney’s title, A Crusade Against Home Birth. I have to give her credit for encapsulating in a so words the self-pity, conspiracy theories and mendacity that are at the heart of homebirth midwifery.

Instead of responding to a scientific article with a scientific analysis, Cheyney signals from the get-go that she will be using a tactic perfected by the tobacco industry. SourceWatch describes the tobacco industry’s attempt to reframe the debate:

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

As the Tobacco Institute explained to its members:

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

Grunebaum wrote an excellent paper demonstrating that homebirth dramatically increases the risk of a baby being born without any sign of life, and Cheyney almost certainly knows that the paper is true. Therefore, she has reframed the debate to switch attention from the scientific evidence (where Cheyney has less than nothing to stand on) to the dire prediction of an extreme outcome, portraying the paper as part of a conspiracy to deprive women of autonomy. The title is the equivalent of: “Don’t look at the growing numbers of dead infants; look over there where evil men are trying to take away your freedom.”

It is repeated within the text of Cheyney’s piece:

This article was not published in isolation, but is part of a larger effort by senior author Dr. Frank Chevernak from Cornell University, who has published at least six other articles critical of home birth in the past 2 years in major obstetrics, pediatrics, and ethics journals (19– 24). A recent article published in Pediatrics is typical of Dr. Chevernak’s work. In it, he claims to discuss the ethics of home birth, but his discussion runs counter to contemporary democratic principles of free choice and autonomy for the expectant mother, and to women’s control over their own bodies…

It’s a conspiracy to deprive women of their freedom!

That’s the exact strategy from the tobacco playbook, and every bit as unethical.

But even Cheyney knows that she has to address the actual scientific paper, so she copies the same strategy that appears to have guided GM: lie, deny, cover up.

Here’s what GM did:

… [B]y the time Benjamin Hair, 20, crashed into a tree in Charlottesville, Va., on Dec. 13, 2009, while driving a Pontiac G5 home, G.M. had conducted five internal studies about the ignition problem, its records indicate. Though Mr. Hair used his seatbelt, he died after the car’s air bags failed to deploy. His parents were baffled. “The police couldn’t tell us what caused the accident,” said Brenda Hair, his mother. The Hairs contacted G.M., providing accident reports but no vehicle data, because the car’s black box had been destroyed. “They came back and said they’d presented it to their board of engineers, and they couldn’t say it was related” to a defect, Ms. Hair said.

It is difficult to comprehend that anguish of losing a child in an accident. How much greater will that anguish be now that Hair’s parents have learned that GM knew all along that their cars had a fatal defect, hid that defect from consumers, failed to repair the defect, and then lied about it when presented with evidence?

Here’s what Cheyney and MANA have done:

1. First, they hid the death rate of homebirth for 5 years.

2. Then when they finally published the death rate, they refused to compare it to the appropriate comparison group (low risk women who gave birth in the hospital in the same years), and instead compared their data to studies from other countries.

3. Although Cheyney and MANA have known all along that their death rates are hideous (hence the decision to hide them for 5 years), they simply lied in their own paper to claim that their data showed homebirth to be safe when their own data shows homebirth to be dangerous.

In other words:

GM hid the existence of the faulty ignition for 5 years
and
MANA hid the existence of dramatically higher perinatal death rate at homebirth for 5 years.

In the wake of accidents involving the faulty ignition, GM claimed to grieving families that there was no safety problem
and
in the wake of homebirth deaths, Cheyney and MANA have claimed to grieving parents that there is no safety problem with homebirth.

While GM’s own data showed that the ignitions were fatally flawed, they went forth and lied about the issue
and
when MANA’s own data showed that homebirth with a non-nurse midwife is fatally flawed, they went forth and lied about it.

In GM’s defense, they did not go as far as Cheyney and MANA. GM could have said that the claims about the faulty ignition were the work of a conspiracy on the part of Ford who only wants to take away the right to drive GM cars or maybe even ALL cars.

Cheyney and MANA appear to have no problem saying that claims of (and scientific papers about) deaths of babies at the hands of homebirth midwives is a conspiracy on the part of obstetricians to take away the right to have a homebirth, or maybe even ALL of women’s rights.

You know that Melissa Cheyney and MANA have gone to a bad place when a major corporation that allegedly hid a preventable cause of death from the public, looks better than professional homebirth advocates.

The analogy is inescapable:

Cheyney and MANA are no different from any organization that tries to hide safety defects from the American public for no better reason than to preserve market share.

You wouldn’t let your baby play in the toilet; why give birth to him there?

Apparently waterbirth proponents can’t figure out how to deal with my “negativity” about waterbirth in the wake of the cautions issued by the American Academy of Pediatrics and the American College of Obstetrician Gynecologists.

It’s not as though any of them could mount a rebuttal to the paper. They haven’t read the literature, wouldn’t know how to understand it if they read it, and couldn’t care less what is says in any case.

So what if babies are injured and die unnecessarily at waterbirth from infections as a result of inhaling fecally contaminated water; umbilical cord avulsion and umbilical cord rupture leading to hemorrhage and shock; drowning or near drowning; and seizures and perinatal asphyxia?

Is that any reason to be so negative?

Ananda Lowe doesn’t thinks so. She is the co-author with Rachel Zimmerman of The Doula Guide to Birth; Secrets Every Pregnant Woman Should Know. Hmmm. Rachel Zimmerman; that name sounds familiar. Oh, I remember why; she’s the doula who authored the piece on waterbirth on WBUR, the Boston affiliate of NPR. Zimmerman revealed her bias by “balancing” the scientific evidence from the AAP and ACOG with the blithering of Barbara Harper, as if a nurse who just makes stuff up provides balance.

Lowe doesn’t like the comments I left on the piece. She wrote an email to her doula list about it and the email was posted on Facebook.

Hi all,

Thank you to those who responded to my previous email asking for your comments on the water birth article that my colleague wrote for the NPR Web site. You truly made a constructive contribution to the conversation.

If you looked at the article, you probably noticed the “flame wars” started in the comments section by Dr. Amy…

… Dr. Amy instigated perhaps the worst comment war I have ever seen her create. There were over 600 comments in just 2 days, many of which are posted by a small handful of people (Dr. Amy’s followers) repeating themselves many times and with extreme hostility. Dr. Amy had posted the very first comment to the article: “Would you completely immerse your head (eyes open, of course) in the fecally contaminated bloody water of a birth pool in the aftermath of a birth?” and the flame war took off from there.

I am curious what our community feels is the best way to handle her and others like her. She has an orchestrated way of disrupting the comments section of articles on a frequent basis. I wonder, should there be an orchestrated response to her, or should some other approach be taken? …

My feeling, and I have heard others speculate, is that she and her followers are acting out their pain over their own difficult births or difficult breastfeeding experiences and lack of support for mothers in our society, or other difficult experiences in their lives that somehow come out in their anger toward the natural childbirth community…

I myself do not have a lot of time to devote to a campaign to dealing with Dr. Amy. But she seems to be getting more and more wild, if that is possible, and I would be interested in hearing your ideas about relating to bullies in general, as well as those who inflame the childbirth wars and mommy wars in particular.

Ananda Lowe

How sad. I’m harshing the mellow of doulas and natural childbirth advocates everywhere and for the absolutely trivial reason that babies are being harmed by being delivered into the equivalent of toilet water.

Here’s a thought, Ananda:

Instead of reflexively opposing anything that calls your birth “knowledge” into question, maybe you ought to consider that the American Academy of Pediatrics Committee on the Fetus and Newborn knows much more about neonatal physiology than all the doulas in the country put together. They have no reason to claim that waterbirth injures and results in preventable deaths of babies unless it does. Y0u are wrong and babies are suffering because of your lack of knowledge, and the willingless of natural childbirth advocates to privilege process ove3r outcome.

We have a saying in medicine that doulas might want to take to heart: Primum non nocere. First, do no harm.

Waterbirth can and does harm some babies. That’s not negativity. That’s the truth.

Deal with it!

I’ve been wondering about the professional ethics of the American College of Nurse Midwives for years. Although they are well aware that American homebirth midwives, CPMs, LMs and DEMs are substandard practitioners, (even acknowledging it within their own publications), they have repeatedly allied with them. I’m not sure why they don’t see that it is harming their own reputation, but apparently they operate by the theory that “the enemy of my enemy is my friend.”

So their professional ethics have been suspect from the get go, appearing as it does that the ACNM values professional autonomy over the lives of babies and mothers. That impression of professionally unethical behavior was strengthened when the ACNM came out with a bald faced lie about the reliability of birth certificate data to support MANA in claiming that homebirth is safe when MANA showed quite clearly that it is not.

Now comes word that the ACNM is preparing to go even farther in unethical behavior. A new memo alerts CNMs that their organization “disagrees” with the American Academy of Pediatrics Committee of the Fetus and Newborn and the American College of Obstetricians and Gynecologists that waterbirth poses deadly risks to babies.

Are we really supposed to believe that a bunch of certified nurse midwives knows more about neonatal physiology than a group of neonatologists and perinatologists? Maybe ACNM believes it, but no one else will. Are we really supposed to believe that CNMs care more about whether babies live or die than the people who actually care for and save the lives of those babies? I doubt even the ACNM believes that. But what they apparently do believe is that waterbirth is their “turf” and just because a bunch of babies died from inhaling birth pool water contaminated with feces, or died of hemorrhage because their umbilical cords were torn off as they were lifted from the pool, is not reason enough for them to tell the truth about waterbirth.

The ACNM set out a memo to its members this morning:

ACNM believes this document does not accurately reflect the large and growing body of research that supports water birth as a reasonable choice for healthy women experiencing normal labor as well as birth.

What large and growing body of research? The ACNM doesn’t say.

Most water births occur under the care of a midwife and it has been a safe option for decades that provides comfort with good outcomes for the mom and her baby.

No one said otherwise. Most of the time giving birth in water, despite being non-physiologic and despite being dangerous, will end fine. But, of course, most of the time not buckling your infant into a car seat will end fine, too, yet we don’t say to mothers that if not buckling their infants into car seats improves the mother’s experience, she doesn’t need to use a car seat. Our babies are precious to us, and we want to mitigate risks of death, even when those risks are small.

However, this new ACOG/AAP opinion statement cautions about immersion in water during the second stage of labor. These cautions are similar to those in their prior publications, including warnings about a lack of data on the safety and benefits of water birth. The organizations refer to case studies of adverse outcomes, but case studies are not a reliable form of research, and should not be the foundation for their conclusion—that water births should only be considered as part of “experimental” clinical trials.

Case studies are generally the first warning sign that a medication or procedure is dangerous. For example, the companies that made a certain type of artificial hip presented a number of studies demonstrating the benefits of their new hip. The device was introduced into clinical practice based on those studies. It wasn’t until doctors began reporting unusually early failures of the device that both patients and physicians were alerted to the high failure rate of these devices.

The ACNM is either disingenuous or uneducated about the value of case studies in exposing unusual risks that occur unexpectedly when new medications, devices or practices are introduced.

Despite limitations, the best available research indicates that water birth is associated with perinatal outcomes similar to those expected in a low-risk population. In other words, healthy women and their babies generally stay healthy during and after normal labor and water birth. Therefore, water birth is a reasonable choice for healthy women to make in collaboration with their care provider, given the state of the science.

All you have to do is ignore the dead babies and you can keep recommending waterbirth!

The ACNM should be ashamed of themselves. They are placing their turf battles above the lives of babies who didn’t have to die. They are no different from Big Pharma who, when faced with case reports that a blockbuster drug has unexpectedly killed people it was supposed to benefit, insists that “their” safety data shows that the drug is safe and tthat no one needs to be warned about any risks.

Maybe things have changed since I practiced for years with dozens of CNMs. Those women cared just as much about babies as I did. They were highly educated, highly trained, and scientifically rigorous. Maybe I am naive, but I can’t imagine a single one caring more about her turf than about providing accurate information to mothers so they could make the choices that were right for them and their babies, not the choices that were advantageous for midwives.

The current leadership of the ACNM is apparently different:

Additional information will be forthcoming to members in the coming weeks to further support our collective efforts to maintain women’s access to water birth under appropriate conditions. These include:
• An official ACNM position statement on Hydrotherapy During Labor and Birth
• Articles to be published in an upcoming issue of JMWH
• ACNM’s official response to the ACOG/AAP committee

I can’t speak for others, but for me whatever the ACNM has to say is going to be ethically suspect. I don’t believe that they have even a tiny fraction of knowledge of neonatal physiology as neonatologists and perinatologists so their opinion is pretty worthless. And unlike neonatologists and perinatatologists who have no plausible reason to inflate the dangers of waterbirth, CNMs have an utterly self-serving reason to dismiss those risks; their desire to hold on to “turf.”

The ACNM commitment to “normal birth” and their cavalier willingness to dismiss babies who die at waterbirth reflects their preoccupation with processes that they can control and their demonizations of skills and procedures that are beyond their their education and training. But caring for women in childbirth is not supposed to be about process; it’s supposed to be about outcome, a healthy baby for a healthy mother.

The truth about waterbirth threatens CNMs. They’d rather suppress that truth and threaten babies lives.