The practice of waterbirth, widely beloved of natural childbirth and homebirth advocates, is nothing more than giving birth in a gigantic fecally contaminated toilet.

There is no difference at all.

Wait! Scratch that; there is one difference. Toilet bowl water is room temperature, leading to slower growth of microorganisms. Birth pools are heated to body temperature, the favorite temperature of harmful bacteria and the one that allows the bacteria to multiply to pathogenic levels.

The American Academy of Pediatrics’ Committee on Fetus and Newborn in conjunction with the American College of Obstetricians and Gynecologists has just updated its position on waterbirth. Nothing has changed since the previous edition published in 2005, except in the intervening years, more cases of perinatal death and injury have been reported.

The scientific evidence for giving birth in water has failed to demonstrate any benefit, but case reports have demonstrated a wide variety of risks:

Some of the reported concerns include higher risk of maternal and neonatal infections, particularly with ruptured membranes; difficulties in neonatal thermoregulation; umbilical cord avulsion and umbilical cord rupture while the newborn infant is lifted or maneuvered through and from the underwater pool at delivery, which leads to serious hemorrhage and shock; respiratory distress and hyponatremia that results from tub-water aspiration (drowning or near drowning); and seizures and perinatal asphyxia. (my emphasis)

But wait! Barbara Harper, the nurse who is the doyenne of American waterbirth claims that infants can’t breathe in the contaminated bathwater because the “diving reflex” prevents them from gasping.

Not so, according to the AAP and ACOG:

Although it has been claimed that neonates delivered into the water do not breathe, gasp, or swallow water because of the protective “diving reflex,” studies in experimental animals and a vast body of literature from meconium aspiration syndrome demonstrate that, in compromised fetuses and neonates, the diving reflex is overridden, whichleads potentially to gasping and aspiration of the surrounding fluid.

We know that fetal breathing movements (aspirating amniotic fluid into the lungs and out again) is a part of normal lung development. If there is not enough amniotic fluid, the baby’s lungs will be fatally underdeveloped (Potter’s Syndrome). And the presence of fetal breathing movements in utero is a sign of fetal well being when seen on ultrasound. So we know that babies breathe in and out in the uterus, even when they are well oxygenated, and we know that babies who are oxygen deprived breathe meconium into their lungs. It is the height of foolishness to claim that they won’t breathe fecally contaminated birth pool water into their lungs as well.

Most mainstream media outlets have covered this story by providing the facts. Unfortunately, the health column for WBUR, the Boston affiliate of NPR, is written by a doula, Rachel Zimmerman, among others. Zimmerman revealed her bias by “balancing” the scientific evidence from the AAP and ACOG with the blithering of Barbara Harper, as if a layperson who just makes stuff up is the equivalent of balance.

There’s currently a vigorous debate going on in the comments section, and I predict it is only a matter of time before Zimmerman starts deleting comments.

The bottom line is that waterbirth is no different from delivering in a giant toilet warmed to the preferred temperature of fecal bacteria. It is unnatural (no primates give birth in water); it is dangerous; and it is ludicrous to claim otherwise.

I have a simple question for waterbirth advocates:

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?

I have a second question:

If you wouldn’t for a moment contemplate immersing your head in a pool of water with feces floating in it, why do you think it is a good idea to force your baby to do so?

American homebirth midwives, like all quacks, are incredibly paternalistic.

That’s because when a homebirth midwife admonishes a client to “trust birth,” what she is really means is “trust me.”

She’s decided to gamble with your baby’s life … literally. She bets that the odds of everything working out fine are high enough that she can put your baby’s life down as her marker and you will walk away with a live baby. She doesn’t plan to do a single thing to improve the odds, since she doesn’t know how to do anything to improve the odds, besides dial 911 and get real medical professionals involved.

She is no different from an gambler who asks to borrow $5000 to invest in a deal that “can’t go wrong.” You’re a fool if you hand over the money and you’re a fool if you hire a homebirth midwife.

I wrote earlier this week that homebirth midwives have a one size fits all approach to pregnancy and birth. That’s because they “know” that everything is going to work out fine. Obstetricians, on the other hand, despite their tremendous reserve of obstetric knowledge and experience, freely admit that they don’t know how your pregnancy and birth is going to turn out. And because they don’t know for sure that everything is going to be fine, they recommend everything that can raise the odds that your baby will be fine. That includes prenatal testing, ultrasounds, prophylactic treatments, fetal heart rate monitoring, and giving birth in a place that has the emergency equipment and personnel to handle just about any disaster, whether it was predicted in advance or not.

Although most of us find comfort in certainty, by the time we’ve become adults, we recognize that there is very little certainty in life. We buckle our seatbelts in the car, not because we think we are going to be in an accident; we don’t. We buckle them because we want to be prepared for the rare but life threatening possibility that we will be in a car accident. We try to eat healthy and exercise, not because we believe that we will definitely get ill otherwise, but because we want to decrease the odds of getting ill to as low as we possibly can. We seek shelter during a lightning storm, not because we are sure that we will be struck by lightning if we stand in the open, but because we want to minimize the chances that disaster will happen.

Homebirth midwives are masters at emotional manipulation and they recognized long ago that there was not going to be much profit in telling women “Trust me to be sure that everything is going to work out fine even though I am just a layperson with no idea how to prevent or treat disaster.” So instead they hit on the idea of telling women “trust birth.”

It sounds so much more transgressive and romantic, to trust birth than to trust obstetricians. The irony is that obstetricians aren’t asking you to trust them. They are admitting up front that they can’t guarantee your baby’s health (or your health), but they can do a wide variety of things (tests, treatments, etc.) to dramatically raise the odds that your baby will be fine. They have the track record to prove it. Over the past century, modern obstetrics (and pediatrics and anesthesiology) have dropped the neonatal mortality rate by 90%. And it didn’t drop because they trusted birth.

There’s also a quasi-religious element to trusting birth, as if Birth were a goddess that requires your praise and your sacrifice. The implication is that if you trust “her,” Birth won’t ever send complications your way. Homebirth midwives, in this scenario, are like those who practice religious snake handling:

… the religious ritual based on a Bible passage: People hold deadly snakes, believing that a poisonous snakebite won’t hurt anyone “anointed by God’s power.”

Similarly, homebirth midwives, the high priestesses of Birth, hold babies’ lives in their hands, believing that Birth won’t hurt anyone anointed by her power.

Inevitably, many of these snake handlers die, even the one who had his own reality TV show:

Tragedy struck [Pastor] Coots this past weekend when he died of a rattlesnake bite during a church service — following his wishes, his family reportedly refused medical help …

Inevitably, tragedy will strike homebirth advocates, too. Their babies will die at even higher rates than those who didn’t trust birth. The critical difference, though is that Pastor Coots chose to gamble with his own life. Homebirth midwives and advocates choose to gamble with a baby’s life, a baby who had no say in the matter, but surely wanted to live.

Homebirth midwives are gamblers and they their gambling has quasi-religious overtones. Just cede all control to them; your baby’s survival is a sure thing, so long as you trust them birth.

Make no mistake. Homebirth midwives, like all fundamentalists, are deeply paternalistic. They “know” what you should do. They “know” that everything will turn out fine. They “know” that if your baby dies it isn’t their fault; it’s your fault for not believing enough in birth.

Homebirth midwives are con artists whose only redeeming feature is that they actually believe their own con. But that’s not particularly surprising since they are too uneducated and untrained to believe otherwise.

So women who are contemplating homebirth need to ask themselves:

Do I want to bet my baby’s life that a layperson can predict the future?

Do I want to bet my baby’s life that Birth will protect my child if I just believe fervently enough?

Or am I mature enough to recognize that the world is full of uncertainty, no one knows what the future holds, and those who take precautions are more likely to survive than those who don’t?

The con artist knows that the con is always more comforting than reality. The real question for mothers contemplating homebirth is whether they prefer the paternalism of the con over the uncertainty of reality … and are they willing to risk their babies lives in exchange for the comfort of trusting birth?

Homebirth midwives don’t have a motto, but if they did, I propose the following:

Nobody ever went broke underestimating the intelligence of the homebirth advocate.

If you think that’s not snappy enough, they could just shorten their motto to this:

There’s a sucker born every minute.

Don’t believe me?

Consider today’s post from Gloria Lemay, the Canadian version of Australian killer midwife Lisa Barrett:

I discourage routine ultrasound and recommend that dopplers and imaging devices be kept well away from the developing fetus.

But women still want to see how the baby is doing inside the uterus, so she offers them a nonultrasound solution. (The picture is NSFW, but only because it will make you laugh out loud, so be prepared before you click on it).

This is part of the growing amount of cargo cult science in homebirth midwifery.

What is cargo cult science?

Physicist Richard Feynman coined the expression in his 1974 commencement address at CalTech.

…In the South Seas there is a cargo cult of people. During the war they saw airplanes land with lots of good materials, and they want the same thing to happen now. So they’ve arranged to imitate things like runways, to put fires along the sides of the runways, to make a wooden hut for a man to sit in, with two wooden pieces on his head like headphones and bars of bamboo sticking out like antennas –he’s the controller– and they wait for the airplanes to land… So I call these things cargo cult science, because they follow all the apparent precepts and forms of scientific investigation, but they’re missing something essential, because the planes don’t land.

More familiar examples of cargo cult science include the TV shows Gilligan’s Island and The Flintstones. The Professor on Gilligan’s Island used coconut shells to mimic all sorts of technology, like telephones, and, because it looked like the item of technology, it worked like the item of technology. Similarly, when Wilma Flintstone vacuumed her living room floor with a baby mammoth on wheels, we were to assume that because it looked like a vacuum cleaner, it functioned like a vacuum cleaner.

Melissa Cheyney and Oregon homebirth midwives were the first to employ cargo cult science in homebirth midwifery by creating Auscultated Acceleration Testing, the cargo cult version of the non-stress test (NST).

Now Gloria Lemay has gone them one better with the cargo cult version of ultrasound. Just like real ultrasound it creates an anatomically detailed image of the developing fetus. You can send pictures of it to your relatives and friends and post it on Facebook just like other women post their ultrasound picture.

Here’s what I’m puzzling over: Does Gloria Lemay think that homebirth advocates are morons and will find the image useful? Or does she think they are such simpletons that they will actually believe that there are benefits to the image? Or is it supposed to be a statement? Other women may expose their babies to ultrasound, but I can find out everything I need to know with a drawing.

In any case, she is certainly operating by the motto that there’s a homebirth sucker born every minute.

Homebirth midwives often proclaim that they offer more personalized care than obstetricians. The truth is 180 degrees opposite from the claims.

I suppose that if homebirth midwives mean that they have nicer personalities than obstetricians (more personable care) or that they will spend more time discussing intimate details of your life that have nothing to do with birth (inappropriately personal care), they are correct. But when it comes to care based on the precise medical situation of the mother, obstetricians are lightyears ahead of homebirth midwives.

I’ve always known this, but my recent attendance at an “updates in obstetrics” reinforced the point. Over the course of two days, I attended 16 sessions on a variety of obstetric topics and every single session was, in essence, about the discoveries that allow obstetricians to counsel and offer care to women in ways that are ever more personalized. Almost all the sessions involved case scenarios:

Prenatal testing: the mother is under 35 with no family history of Down Syndrome, over 35, with a family history, with a previously affected child, etc. etc.

Premature labor: the mother is white, is African-American, has no history of prematurity, has multiple previous premature births, membranes are intact, membranes are ruptured, etc. etc.

VBAC: previous C-section for a non-repeating cause, for a repeating cause, previous vaginal delivery before or after C-section, no previous vaginal delivery, baby is big, baby is small, mother has normal BMI, mother is obese, etc. etc. etc.

After each session there were questions from participants and almost all of them were case scenarios (almost certainly real cases that the questioners had faced or were facing). Nearly all the questions took the same form: these are the patient characteristics, this is the problem, what shall I tell her about what is likely to happen and what we should do about it?

Homebirth midwifery, in contrast, is one size fits all.

Personal characteristics are irrelevant. Advanced maternal age, maternal obesity, pre-existing maternal disease? It doesn’t matter because the counseling and treatment plan are always the same: you can and should have a homebirth.

Medical history is irrelevant. Had a previous shoulder dystocia, C-section, postpartum hemorrhage? Who care? You can and should have a homebirth.

Complications are irrelevant. Baby is breech, have gestational diabetes, colonized by group B strep? Who cares? You can and should have a homebirth.

Labor complications are irrelevant. Dysfunctional labor, prolonged rupture of membranes, pushing for 4 hours? Who cares? You should still stay home because you can and should have a homebirth.

Why do homebirth midwives have a one size fits all approach to pregnancy and childbirth?

Two reasons: ignorance and dogma.

Homebirth midwives are lay people. They basically acknowledge that fact by calling themselves “experts in normal birth,” since most laypeople could easily deliver a baby in the absence of risk factors and complications.

Homebirth midwives have literally no idea of the breadth of possible complications, the effect of various risk factors, the many variations of abnormal in pregnancy and birth. Moreover, they are not able to deal with risk factors or treat complications. If they acknowledge them, they will have to transfer the patient to the care of an obstetrician and lose the fee and the birth junkie high. Instead they paper over their ignorance by declaring that whatever happens makes no difference at all. It doesn’t matter that they cannot anticipate, diagnose and manage complications when everything is a “variation of normal” and the treatment is always to forge ahead with a homebirth.

Ultimately, though, it comes down to the dogmatic cult-like believe in unmedicated vaginal birth. They appear to be unable to fathom the concept that childbirth is dangerous for both babies and mothers. Just like the flat-earthers maintain that the world is flat because that’s the way it seems to them, homebirth midwives maintain that childbirth is safe because that’s the way it seems to them. It simply never occurs to them that their relentless emphasis on unmedicated vaginal birth can and does kill babies and mothers. They literally cannot accept the evidence that is right in front of their eyes, so they deny it (“some babies are just meant to die” sounds so much more soothing than “we tried so hard for a vaginal birth that we killed the baby”), or, in the case of homebirth midwifery leaders like Melissa Cheyney, they tell bald-faced lies about it, claiming that their own hideous death rates are “safe.”

Women who are contemplating homebirth need to ask themselves whether they value obstetric care, which is personalized to their specific circumstances in this specific pregnancy, or whether they’d prefer a one size fits all approach. Obstetric care is personalized because the goal is a healthy mother and a healthy baby. Homebirth midwifery is one size fits all because the goal is unmedicated vaginal birth; if the baby and mother survive without injury, that’s simply a bonus.

On Sunday and Monday I attended a Harvard Medical School annual review of obstetrics. One of the sessions that I was most eager to attend was the session on maternal mortality, and it did not disappoint. The most intriguing aspect was that the crisis in maternal mortality is almost exactly the opposite of what natural childbirth activists claim. Simply put, the crisis is not the over use of technology, but rather a mismatch between the number of pregnant women with pre-existing complex medical problems and the dearth of specialists and specialty units with the appropriate expertise to care for them.

The threshhold question, of course, is whether US maternal mortality is increasing. I’ve written about that many times over the years, and the speaker pointed out that it is probably not increasing; the apparent increase that we have seen (from 10.4-14.5/100,000 between 1990-2006) almost certainly reflects the ongoing efforts to appropriately classify deaths that occur in the wake of pregnancy. In other words, the rate of maternal death is not rising, the accuracy of our statistics is rising.

Be that as it may, maternal mortality is certainly not falling, and maternal morbidity (complications that do not result in death) is rising. Most importantly, the profile of maternal mortality is changing, as illustrated by the following graph from the paper Pregnancy-Related Mortality in the United States, 1998 to 2005 (the markings were added by the speaker).

Note that the traditional killers of pregnant women (hemorrhage, pre-eclampsia/eclampsia, blood clots) are being supplanted by new killers including pre-existing heart disease, cardiomyopathy of pregnancy (a weakening of the heart muscle) and other complex medical conditions. Indeed, while the death rate from traditional causes of maternal mortality has been steadily falling, the death rate from unusual causes has been steadily rising.

This almost certainly is a reflection of the increasing age and increasing obesity of pregnant women. So while complications from vaginal birth and C-section (infection, bleeding and blood clots) are still important causes of death, they are being supplanted by pre-existing medical conditions. We can and should work to decrease traditional causes of maternal death. For example, treating women with short courses of blood thinners around the time of surgery could drive down the rate of blood clots much further. However, the real crisis in maternal mortality is that we have not responded effectively to the increasing medical needs of pregnant women.

The speaker compared our response to maternal mortality with our response to perinatal mortality and raised an issue so obvious that I’m embarrassed that I hadn’t thought of it before. The dramatic decrease in perinatal mortality over the past 50 years reflects the creation of a specialty devoted to critically ill newborns (neonatology), specialty units for the care of critically ill newborns (neonatal intensive care units, NICUs), a rating systen for hospital nurseries (levels I, II, and III) to facilitate triage and transport of critically ill newborns to hospitals that have the experts and equipment to to treat them.

We have done nothing similar to address the increase in critically ill mothers. Although the number of pregnant women requiring intensive care is increasing, there are very few obstetric intensivists, very few obstetric intensive care units, and no rating system to facilitate transfer of critically ill mothers to hospitals that have the experts and equipment to treat them.

This image graphically represents the difference in our approach to preventing maternal mortality vs. preventing perinatal mortality.

In contrast to a wide variety of protocols defining best care practices for high risk perinatal complications, there are virtually none for high risk maternal complications.

The bottom line is that the solution to any crisis in maternal mortality is NOT indiscriminately decreasing interventions, since obstetric interventions are not the proximate cause of most cases of maternal mortality. It is imperative that we INCREASE our ability to identify critically ill pregnant women, transfer them to specialty obstetric units that have the personnel and equipment to manage their complex medical problems so we can apply MORE interventions to those complex medical problems, and identify best practices for managing complex medical conditions in pregnancy.

We may not have a crisis in maternal mortality yet, but if we fail to take these steps, we almost certainly will.

It’s been a depressing series of decades for those who find deep and abiding satisfaction in bullying others. You can no longer shame people for being divorced or for having a child without being married. You can’t look down on people of different races, sexes or religions. You can’t shame people for being gay and at the rate things are going, it won’t be long before it will be frowned upon to shame people for being overweight.

But, in this world of ever decreasing shaming opportunities, there are still some tried and true options available. You can still shame another women for being a bad mother. In fact, not only are the old options available (“I can’t believe your 14 month old is not walking”; or “My Johnny is always picked first for sports teams”; not to mention the ever popular “I’m so sorry that your child is going to a state college and not the elite college my child is attending.”), there are some outstanding new options. These include shaming women about the births of their children, and shaming them if they did not meet an your preferred length of breastfeeding, or (heaven forfend!) never breastfed at all.

The new methods for bullying/shaming mothers are just as satisfying as the old ones, but they have one important advantage. With the old methods, it was regrettably clear that the only person benefiting from shaming was the person doing the shaming. With the new methods, you can actually pretend that you are shaming another mother, not merely for her benefit, not merely for her child’s benefit, but for the benefit of society. It’s a win-win: all the fun of bullying another mother plus a dollop of self-righteous concern for public health.

Another benefit of the new shaming methods is the opportunity for creativity. So many of the old methods were restricted by the need to tell the truth whereas lying is not merely permitted in the new methods, it is positively encouraged. There’s no need to stick to the actual risks of cesareans or pitocin when so many attractive lies exist: they cause autism, they destroy gut bacteria, they change the very genes of the baby! So not merely is another mother a total loser for having a C-section, she can be shamed for actively harming her baby.

The same creativity applies to the benefits of breastfeeding: it prevents every disease known to man; it cures every disease known to man; there is no problem that exists that cannot be solved by squirting breast milk at it! When a mother is unwary enough to acknowledge in your presence that she doesn’t breastfeed, you can accuse of harming her child, AND being a selfish slob who puts her convenience ahead of her child’s brain functioning. It’s hard to imagine more satisfying bullying then that.

But it isn’t enough merely to bully women one on one; bullying can be institutionalized. Baby Friendly Hospitals represent breast shaming on steroids. Locking up formula in hospitals is oh so painful for mothers and so satisfying for shamers. If only they could require prescriptions for formula, breast bullies’ lives would be complete. And best of all, they are doing the shaming for the public good!

That’s why any attempt to inject sanity into debates about childbirth or breastfeeding must be resisted vociferously. How dare any expert point out that C-sections are often better for babies than vaginal birth? How dare any expert claim that you can raise an intelligent child without breastfeeding? Isn’t any form of shaming sacred anymore?

Being a bully is fun! Being a birth or breast bully is better than fun; it is a public service. They may have taken away the shame of illegitimacy. They may have made gay jokes socially unacceptable. It’s only a matter of time before fat shaming is frowned upon. But when it comes to birth and breast bullying, the sky is still the limit!

Dr. Gorski has expended literally thousands of words on me, but I don’t think he’s worth more than a few of mine. Here’s my response in the form of a limerick:

There was an old skeptic from Boston
Who mourned babes when midwives lost ’em.
Then an ass from Detroit,
Conflict keen to exploit,
Salved his ego and carelessly tossed ’em.

“Medwife” is a term of derision typically applied by lay midwives (CPMs, LMs, DEMs) to real midwives, certified nurse midwives (CNMs), to signify disgust with using actual medical knowledge in the care of pregnant women. This “medwife” wrote to me in the wake of baby Gavin’s death to express her sorrow at such a needless, senseless loss of life. During the course of our correspondence, she explained her philosophy to me so eloquently that I asked for permission to publish it as a guest post.

On being a Medwife:

I do not believe babies know when to be born at either end of the spectrum. I am certain no baby intends to die in his mother’s arms on the verge of viability or in her womb pushing well beyond the dates. I use tocolytics to provide steroid administration and provide neuroprotection, 17P to prevent a subsequent premature birth. I believe frequent antenatal testing provides a level of reassurance beyond 40weeks, but will nudge your baby along at 41 weeks with little left to gain from conservative management regardless of the reassurance.

I believe our bodies do grow a baby too big for us and I believe shoulder dystocia is a sentinel event even in the hands of the most experienced providers. It is not a situation caused by poor maternal positioning or relieved by Gaskin maneuver and certainly not in a bathtub of your living room. Watching a healthy baby die on the perineum is a vision to haunt your nightmares for a lifetime.

I don’t believe in the 39 week rule. It will prevent some early term birth admission to a NICU, but will also cause hesitation by providers to act for fear of statistical outliers and repercussions. I will play within the rules, but will not ignore the soft indicators or the intuition to act upon them.

I believe babies have a due date, placentas expire and not much good comes after 41weeks. I do not believe waiting for a baby to display signs of decompensation is the time to act. Perhaps a poor tracing, MSAF and a neonatologist fit into your 41 week plan, but then again perhaps you didn’t really want the intermittent monitoring, minimal attendants and delayed cord clamping.

I believe in preeclampsia. I respect its etiology, pathology and spectrum of progression. No diet, herb or pressure point will prevent the sequence of severity. If you argue or ignore the recommendation to move towards immediate delivery and days later your ICU admission or eclampsia means crash carts and ventilators…your partner has officially forfeited his right to ask “wasn’t there anything you could have done to have prevented this?” I will just walk away.

I believe GBS treatment does not include garlic or tea tree oil. Protecting your baby’s gut flora may seem so important now, but means so little in light of GBS meningitis and seizures or the dopamine drip in the midst of septic shock should it be your baby that becomes the statistic.

I believe in VBAC with a heplock, continuous EFM and my OR team within feet of your room. I will not push the limits. As wonderous a window into the womb as your translucent uterine serosa may be, its presence means this OR is just where you needed to be.

I believe twin births in a dimly lit room with hushed voices can be safe, but that room is best located as an OR and behind those dim lights and hushed voices lies the wonder and safety net of an OB, anesthesiologist and neonatologist.

I believe in Vitamin K. Your fears should lie not in the process of administration or theoretical risk of preservatives, but in the absence of its existence. The process or risk will be far from thought if your child is the child flown to tertiary care with ever expanding head circumference and abnormal neurologic exam.

I believe in Rhogam, its safety and its efficacy. Your unfamiliarity with hydrops fetalis in an era of rare sensitization does not lessen its impact on your baby when undergoing MCA Doppler flows, premature delivery and multiple blood transfusions. Your decision to ignore the real risks and let fear based blogs will not prevent this from being your baby or your regrets.

I believe in breastfeeding, BUT I refuse to allow a mother to feel any less a mother for how she chooses to feed her baby. You may never know what lies behind her decision to bottle feed, but you have an obligation to respect and honor it. Just as labor and birth is one miniscule step in the process of mothering, so is feeding method. In several years no one will know who was born how or who was fed what. It really is that simple.

I believe in the wonder of birth. An unmedicated natural birth and it still leaves me in awe of its beauty, but I also comprehend its functionality. Your coconut water, lavender and doula make you no stronger a woman than the woman next door with a continuous epidural catheter or the mother down the hall lying on the OR table laughing and smiling at her baby’s first cry. Birth is amazing, but it isn’t how we determine our strength.

I believe in interventions from AROM to EFM to Pitocin to forceps to cesarean birth. My responsibility is to observe for progress and wellbeing, as well as to utilize the interventions at modern medicine’s disposal to ensure the safest path and highest outcome. Although I cherish and find reward in the intimate relationship we develop over the course of your care, my responsibility is to the health and well-being of you and your baby. Do not confuse my caring and compassion as a desire to become your friend. I will hold your hand, I will be compassionate…but I will not be afraid to use my ‘dead baby card’ or alter my care to avoid ‘hurt feelings”. If that is what it takes to make you realize these evil interventions stand between the health of you and your baby or the risk to disability or death, I will play my ‘card’.

I believe in doulas by definition, not as adjunct providers. The security and support of a doula can be a positive contribution to your birth experience, but so can your labor and delivery nurse. Please don’t discount the skill and support of your nurse and don’t use a doula to make medical decisions. She has not the training or authority to do so. Your doula is there to support you through labor, not create an atmosphere of animosity.

I will listen to the woo and my office schedule will fall behind, but I will gain the trust that keeps you here and not in the hands of an unregulated, unaccountable and uneducated CPM or lay midwife . I will listen to words of concern, because I believe every mother inherently seeks to protect and desires the very best for her baby. I will seek to clarify, educate and empower in order for others to comprehend the science behind the care I provide and the recommendations I make. My care and recommendations will be based upon guidelines, developed and supported by the highest level of scientific evidence; not chat rooms or anecdotes. I will do this because it is my responsibility as a health care provider and is not intended to cause fear or to disillusion ignorant bliss.

I am saddened by the liberal application of the title ‘Midwife’. I am disheartened when my years of formal education and commitment to continuing professional growth are soiled by the unprofessional and unregulated ranks of others who feel it is their right to share this title. As much as I looked forward to holding the title of “Midwife” I feel relegated to distinguish myself from it.

As others attend Blessingways, perfect the art of holding space and call themselves midwives… I will sit here and read my Green and Grey journals, among RN’s, CNM’s and Physicians. For I am the Medwife and I will be here alongside my colleagues, our resources and interventions keeping birth safe…ready, willing and able to identify and intervene when it’s not. If in so doing I am less the Midwife and more the Medwife, there are no regrets.

I don’t think it’s much of a secret that there is animus between Dr. Gorski and myself since I quit the blog Science Based Medicine. It’s pretty obvious that’s why Jamie Bernstein asked Dr. Gorski to adjudicate our “kerfuffle.” (Just as an aside, why do men with substantive disagreements have principled arguments, but women have “kerfuffles”?)

That animus probably led Gorski to publish a screed instead of mediating privately. And it was probably what led him to write a long post about me instead of answering a simple question in a few sentences.

So I’m not telling you anything beyond what is obvious about the gusto with which he approached his task. I’ve never spoken publicly about that animus until now. The moderation policy was the proximate reason for my decision to leave SBM, but not the real reason. The reason why I quit SBM is because I felt Gorski was trying to force me out. Why? Because he felt threatened.

I write in a similar take no prisoners style, and I was attracting a tremendous amount of traffic. I threatened his dominance and popularity within the SBM universe.

Did Gorski ever say that to me? No, but it’s what I felt.

There was nothing wrong with what I wrote for SBM. Indeed, every word was approved by Gorski before it was published. Moreover, as far as I know, every word is still on the site years later.

It wasn’t because I didn’t draw traffic because I drew a lot, although curiously Gorski would never let me see the actual figures.

Nonetheless, despite having approved my posts before he published them, he developed a habit of entering the comment section to criticize me. I looked, but I couldn’t find evidence that he did that to the other members of SBM.

Gorski maintained a double standard for himself and me. He privately admonished me for re-using posts from my personal blog, yet he did it all the time.

I felt strongly that the more popular I became, the more likely I was to be forced out, so I quit. I didn’t need to write for SBM; they had asked me to do so. In fact, it was Gorski himself who asked me, and it was to him that I sent samples from my own blog illustrating my style and emphasizing that I wasn’t planning on changing it.

So now you know why I left SBM, and why Gorski figuratively licked his lips over the opportunity to criticize me.

No one should let that obscure the take away message of Gorski’s post: MANA’s homebirth paper does NOT show that homebirth is safe; it shows that homebirth dramatically increases the risk of perinatal death. For all his wordiness, Gorski disagrees with most of what Bernstein wrote.

It seems to me deeply unfortunate that Dr. Gorski was so keen to settle imagined scores with me that he lost sight of the big picture: irresponsible “practitioners” are lying about the risk of their product, in this case homebirth.

There is one important salutary benefit of the fact that Dr. Gorski approached his opportunity to kick me with so much delight that he actually wrote a screed about it. Going forward it’s going to be impossible for MANA to claim that their paper shows that homebirth is safe.

If I have to take a few public kicks to expose the mendacity of MANA and homebirth midwives, I’m willing (though not happy) to do so.

Over the years I have written many posts about Australian homebirth midwife Lisa Barrett, and the astounding number of deaths at her hands.

I was pleased to see that she was recently fined $20,000 and court costs and reprimanded in the strongest possible terms for her involvement in 4 preventable neonatal deaths.

Should that be the end of it? After reading the report from the Nursing & Midwifery Board of Australia v Barrett, I’m beginning to wonder if these deaths are worth a second look. While reviewing the 4 deaths previously investigated by the Coroner, the Board learned of ANOTHER death that occurred months after the release of the Coroner’s report. I had received information about YET ANOTHER death back in 2009, leading to an extraordinary total of 6 newborn deaths at Lisa Barrett’s hands.

Of these deaths, 1 was a shoulder dystocia, 2 were second twins, and 3 were breech babies. All of the situations were high risk, but even in high risk situations, most babies do fine. We already know that the deaths were preventable; that’s why Barrett has been disciplined. I’m beginning to question whether we need to investigate these deaths further to determine whether Barrett actually let these babies die. In other words, did Barrett fail to provide appropriate homebirth care and make only ineffectual attempts to save the dying babies.

Reading the timeline of the 6 deaths, as well as a near miss twin death described in the board report, and an extraordinarily story of twin birth that Barrett herself has bragged about (49 hours between the birth of the first and second twin), raises the possibility that these babies died not merely because they were born at home, but because of midwife neglect.

The shoulder dystocia death:

The medical expert opined that Barrett had not applied the appropriate maneuvers to deliver the baby:

Professor Pepperell is critical of the respondent’s attempts to extract the baby. The respondent described performing the McRoberts manoeuvre. Professor Pepperell in his evidence said that such a manoeuvre involves placing the mother on her back and lifting her thighs up to her chest so that the angle of entry in the pelvis is different and is bigger in the hope that by doing so the shoulders will then descend into the pelvis. Professor Pepperell when commenting upon the respondent’s evidence34 as to the manner in which she performed the manoeuvre stated that he did not believe that initial traction had been applied appropriately and that it did not appear that adequate suprapubic pressure was ever applied…

A friend of the mother eventually delivered the baby:

A friend of “S” present at the time was asked by the respondent to assist given it was an emergency. The friend was able to put her hand in to grab under the shoulder and was able to pull the baby out…

An experienced midwife was unable to deliver the baby, but a friend of the family simply reached in and dislodged the baby’s shoulder?

Negligent management of twins:

In the near miss twin case, the second twin was ultimately delivered by C-section 8 hours after the birth of the first twin.

As the Board notes:

To allow at least six hours without foetal monitoring of the second foetus after the birth of the first baby is just unbelievable.

In the story on Barrett’s blog, a healthy second twin was delivered 49 hours after the first twin.

Apparently Barrett’s approach to the second twin in these cases was to do absolutely nothing, including no monitoring to determine whether the second twin was in trouble requiring expedited delivery.

The breech deaths:

One breech baby died when Barrett inexplicably stopped checking his heart rate for 24 minutes prior to birth.

So in at least 4 of the 8 cases that I know about, Barrett provided either negligent care, ineffectual care or no care care at all in the midst of obstetric emergencies.

6 confirmed deaths and 1 near miss is an extraordinary amount of bad luck even for an incompetent midwife, and while there is copious evidence that Barrett was reckless there is no evidence that she is incompetent or unaware of the measures used to handle obstetric emergencies.

And these are only the cases that we know about. There could be more.

6 babies are dead and no amount of investigation will bring them back. Barrett has been disciplined under the assumption that her recklessness led to deaths that were unavoidable at home, though easily preventable in the hospital.

But were those deaths at home unavoidable? Or was Barrett’s unwillingness to provide appropriate homebirth care the real cause of at least some of the deaths?