It’s rather amusing watching homebirth advocates thrashing about on the Web, Facebook and Twitter trying to deal with the new paper in the Journal of Medical Ethics equating homebirth to driving without putting a seatbelt on your child.

Before I address what they will do, I can tell you with absolutely certainty what they WON’T do. Despite the fact that the paper indicates that ethicists have now joined obstetricians, neonatologists, and pediatricians to declare that scientific evidence demonstrates that homebirth is not safe, advocates will not even give the slightest consideration to reevaluating their cult-like belief in the safety of homebirth.

It is this, more than anything else, that demonstrates that homebirth has nothing to do with science. For homebirth advocates, the purported safety of homebirth is an article of faith every bit as inviolable as the notion of intelligent design is for creationists. In other words, it is non-falsifiable, a hallmark of a non-scientific claim.

• Homebirth advocates will NOT stop to reflect on the fact that the only people who claim homebirth is safe are homebirth advocates themselves.
• They will NOT undertake a systematic review of the scientific literature that encompasses ALL recent papers on homebirth, not merely the ones they like or the ones they feel confident they can address.
• Homebirth advocates will NOT under any circumstances entertain the notion that they are wrong in their slavish devotion to anything that increases the autonomy of midwives.
• Homebirth advocates will NOT under any circumstances consider that their obsession with process has compromised outcomes.

What will they do?

1. They will fling citations of out of date papers or irrelevant papers. They will cite crappy studies by people like Ank de Jonge who have sliced and diced the data in a thousand ways in a fruitless effort to pretend that homebirth is safe.

2. They will whine that “everything has risks” as if that means they don’t have to consider the specific risks of homebirth.

3. The will invoke the evil triumvirate of doctors/drug companies/formula manufacturers to insinuate that a Professor of Philosophy at Oxford is somehow part of their evil plan to take over the world by making everyone deliver by C-section and then bottle feed.

4. Many will simply ignore what they cannot rebut in the hopes that their followers won’t notice the difference.

In other words, they will do everything in their power to avoid reassessing their immutable belief in the safety of homebirth.

It will be fun to watch homebirth advocates twist themselves into knots to justify ignoring not just obstetricians, neonatologists, and pediatricians, but now ethicists as well.

Finally!

Finally, the dangers of homebirth are gaining attention in the wider scientific community and the lay press.

I’ve been making the homebirth-seatbelt comparison for years (see, for example, Unnecesseat belts from 2011) and now it’s been taking up by ethicists.

The paper Homebirth and the Future Child by OB-GYN Lachlan de Crespigny, and Oxford Philosophy Professor Julian Savulescu is deservedly getting widespread attention in the mainstream media.

From the paper:

Debate around homebirth typically focuses on the risk of maternal and perinatal mortality and morbidity – the primary focus is on deaths. There is little discussion on
the risk of long-term disability to the future child…

… [O]ne silent tragedy is the long-term disability that can result from homebirth. And it is this risk that we will argue weighs heavily against homebirth. In this paper, we will argue that both
professionals and pregnant women have an ethical obligation to minimise risk of long-term harm to the future child…

This is not merely a theoretical argument. I’ve written about several babies who suffered hypoxic brain injury at homebirth:

Conflicted: successful VBAC, brain damaged baby
Another homebirth, another brain injured baby, but the midwife was awesome
Sam: a victim of homebirth
But the baby’s heartrate was fine right before it dropped nearly dead into the homebirth midwife’s hands

Two recent studies, released since de Crespigny and Savulescu submitted their paper for publication, have shown that the risk is extraordinarily high.

The most important paper on homebirth published in 2013 showed that homebirth increases the risk of a 5 minute Apgar score of zero by nearly 1000%!

Grunebaum et al. found:

Home births (RR 10.55) and births in free-standing birth centers (RR 3.56) attended by midwives had a significantly higher risk of a 5-minute Apgar score of zero (p<.0001) than hospital births attended by physicians or midwives. Home births (RR 3.80) and births in free-standing birth centers attended by midwives (RR 1.88) had a significantly higher risk of neonatal seizures or serious neurologic dysfunction (p<.0001) than hospital births attended by physicians or midwives.

A poster entitled Home birth and risk of neonatal hypoxic ischemic encephalopathy, to be presented at the forthcoming February meeting of the Society of Maternal-Fetal Medicine also looks at this issue.

The authors explain:

Women who delivered at home had 16.9 times the odds of neonatal HIE compared to women who delivered in a hospital (p <0.01). The odds remained significant after controlling for maternal age, ethnicity, education level, primary payer and prepregnancy weight (aOR 18.7, 95% CI 2.02-172.47). After controlling for mode of delivery the odds of HIE increased for home birth compared to hospital birth (aOR 32.9, 95% CI 3.52-307.45).

In other words, homebirth increased the the odds of a baby needing cooling therapy for brain damage due to lack of oxygen by more than 18 fold.

Why is there an increased risk of brain injury at homebirth? de Crespigny and Savelescu point to multiple factors.

First:

Homebirth is expected to cause a delay in diagnosis, delivery and/or transfer following an acute intrapartum event with rapidly developing hypoxia, acidosis and asphyxia. Such a delay
will necessarily result in a prolonging of asphyxia. The best intrapartum fetal heart rate parameter for predicting newborn acidemia [ed. decreased blood pH due to low oxygen] is minimal or absent variability, with or without the presence of late decelerations. This is difficult to detect with intermittent auscultation alone, and even if diagnosed there will be the inevitable delay in expediting hospital delivery, which may be time critical…

Second:

[O]xygen, bag and mask ventilation, intubation, chest compressions and resuscitative medications, which cannot be optimally provided in a homebirth environment. It would be expected
that in some cases inadequate neonatal resuscitation will not only convert potential future normality to survival with morbidity, but may also convert potential normality or mild morbidity to survival with major morbidity.

The third factor is delay in accessing treatment for the brain injury:

Transfer of an infant who has suffered a severe asphyxial insult from home to hospital may delay the commencement of neuroprotective strategies, particularly therapeutic hypothermia. This will worsen outcome. The therapeutic window can be too short for infants requiring transfer to a tertiary referral centre.

What about women’s right to choose place of birth?

Homebirth is said to be about the ability of women to make a fundamental choice about their own bodies. Homebirth advocates often wish to keep birth free from medical interventions.
Homebirth decisions may also be influenced by what is fashionable or the latest cause célèbre.

The authors address a variety of legal and philosophical arguments and then conclude:

Having a homebirth may be like not putting your child’s car seat belt on. The risk of being injured in a single trip by not wearing a seat belt is extremely low. Still, we expect people to wear a seat belt to make the risks as low as possible, despite some inconvenience and diminution of driving pleasure. Most children will be unharmed. Some trips are very safe. And
wearing a seat belt will not remove all risk of injury or death. Indeed, wearing a seat belt in an accident will, on rare occasions, cause greater injury than not wearing a seat belt. But on
balance it is much safer with a seat belt…

Homebirth appears to be a risk factor for the future child, or at least so uncertain, that it should be discouraged, pending further research. Doctors and midwives often do not currently tell patients that there are predicatable avoidable risks of future child disability with homebirth. They should do so.

Amen!

It’s very early in the year, and I’ve already heard about two homebirth deaths. The latest was revealed on Reddit:

… active labor was the most beautiful intense experience – the baby had perfect heart fetal tones until crowning where hft dropped to 70 -born unresponsive with heart rate of 90 -3 tears, 8 stitches, 1 of them 2nd degree -child died at hospital

It wasn’t a beautiful experience for the baby, who was dying for minutes or perhaps hours before birth. The baby apparently succumbed to that strange homebirth epidemic that never occurs in the hospital: the baby with “perfect heart tones” who unexpectedly falls nearly dead into the clueless midwife’s hands.

I wrote about similar cases on:
December 27, 2013
September 13, 2013
June 21, 2013
April 29, 2013
March 22, 2013
March 7, 2013
September 28, 2012
August 29, 2012
July 9, 2012
May 10, 2012
December 26, 2011
September 21, 2011
August 31, 2011
July 28, 2011
May 20, 2011
March 24, 2011
February 24, 2011

That’s 17 times in the past 3 years alone that a baby unexpectedly dropped into a homebirth midwife’s hands either dead or nearly so. I have never seen this happen in a hospital. I have never even heard of this happening in a hospital.

What is the mother in the latest homebirth horror story upset about in the wake of her baby’s death?

I was also transported to hospital where I receive two unnecessary pelvic exams

The mother had appeared on Reddit several months before to wail about the “culture of pain” surrounding childbirth:

FTM here looking to have a med free home birth, utilizing visualization, deep breathing and meditation techniques.

I understand this experience is going to be intense, I understand that I have no concept of this experience because I have never gone through it. However, I do not understand why people want to push how much pain I’m going to be in. I’m doing my best I be polite. Explain while intensity will be involved prior events in my life have shown me the amount if pain I feel does seem to be connected to my state of mind. Fear–> anxiety–> tension–> pain DO seem to be correlated. Relaxing ones mind has helped “deal” with things.

And:

This may be my only time I experience this. It’s a thing so intense I could die ( not that I plan to) , and I will be a gateway for a tiny human to enter into the physical plane after having grown inside me from a seed, I’m totally looking forward to this!

As she had hoped, she found labor to be a beautiful, intense experience. Too bad the baby died so she could have that experience.

Apparently in the world of natural parenting, “mom-petition” is not enough. Sure you may have had the longest unmedicated labor, breastfed your child until high school, and risked his life by refusing vaccines, but how’s your sex life?

According to Rose Hollo, crunchy moms do it best! However, after reading her explanation of what makes crunchy sex better, I’m forced to conclude that if this is better sex, crunchy moms have terrible sex lives.

What makes crunchy sex better?

1. Co-Sleeping

Really? Having a toddler or preschooler in your bed makes sex better. On what planet would that be?

2. Breastfeeding

Breasts that used to belong to one’s mate suddenly belong to the baby. The thought of that particular body part being “shared” for different applications is just plain weird for some crunchy mamas. Of course, there’s the milk itself, which leaks and sprays in abundant blessings at the most inopportune times.

Who knew that milk in the eye was erotic?

3. Natural Family Planning:

Expanding on the notion of “inopportune:” Mamas who have recently given birth are believed to be extra-fertile, and are encouraged by doctors to take precautions. But instead of popping a hormone pill daily, many crunchy moms use the “natural family planning” method, or “NFP.” This means that before relations happen, mom must take her temperature, pee on a stick, and record various “signs” into a charting application that tracks her monthly cycle. For those avoiding pregnancy, this time-consuming process is worth it for health reasons. Unfortunately this method is not 100% effective at preventing pregnancy. Those who prefer the “natural” style like to avoid condoms or other devices, so only have relations when they are in the “safe zone” of their cycle. That’s not a great factor in spontaneity.

Well, if that isn’t an aphrodisiac, what is?

4. “Different Down There”

Rose acknowledges that many women are ashamed of their postpartum bodies and we all know how conducive shame is to sex. And let’s not forget vaginal dryness associated with breastfeeding.

*****

Evidently for crunchy mothers, sex is like childbirth and breastfeeding: the more difficult, painful and inconvenient it is, the better it is!

If that what makes sex better, it’s no wonder crunchy mothers are confused on the issue of birth orgasms. It sounds like they may never have had orgasms at all.

Allison Dixley, the self-proclaimed Alpha Parent, is the perfect foil. She’s my go-to source for sanctimony, viciousness, and misinformation on breastfeeding and formula feeding. Now I find out that she is also clueless.

Her most recent post, Embarrassing Tricks of the Mommy Wars, is a delicious illustration of her utter lack of insight. It’s supposed to be an analysis of the faulty logic that opponents use against her, but, instead, it is a shining example of her faulty logic.

Allison writes:

Let’s take a look at the 15 most common badly-thought-out tactics that mothers resort to in their fight for maternal supremacy.

Her cluelessness occurs on three levels. First, Allison fails to appreciate that she routinely uses many of the tactics she despises as illogical. Second, she clearly does not understand specific logical fallacies. Third, many of her examples are not illogical at all. She simply tars them as such in an effort to avoid answering them.

Here are the highlights of Allison’s list, with my comments:

1. The Ad Hominem:

Attacking the character of the person with whom you are arguing rather than finding fault with his or her argument is a technique of rhetoric. As a debating strategy it is an epic fail because discrediting the source of the argument usually leaves the argument itself intact.

That’s rich coming from the woman who routinely refers to formula feeders as selfish cheaters.

2. Anecdotes

The temptation to over-generalize on the basis of a potentially misleading particular experience seems to be irresistible in the Mommy Wars.

I laughed out loud at this one. Every week Allison features “Triumphant Tuesday,” the story of a woman who overcame a specific breastfeeding challenge, aka an anecdote.

3. The correlation =/= causation safety net

If all else fails, recite the mantra “correlation does not mean causation”.

Earth to Allison: Correlation does NOT equal causation. That’s not a logical fallacy; that’s fact.

5. It’s not child abuse

That’s not a logical fallacy; that’s yet another fact. Formula feeding is NOT child abuse.

7. and 8. are “missing the point” the point and irrelevance. Too bad the examples Allison offers fail to illustrate either missing the point or irrelevance.

10. The schoolyard comparison

The Schoolyard Comparison involves the rhetorical question: “In a class of 30 kids, can you tell who was formula fed and who was breast fed?” To which the answer is – of course you can’t bloody can’t. That’s what scientific studies are for.

No, that’s what scientific studies can do when the differences are tiny and not necessarily clinically relevant. It is perfectly reasonable to question the supposed superiority of breastfeeding by asking if it has any real world advantages. If there are no advantages, or the advantages are so trivial that you have to do a scientific study to establish them, you can’t really make the case that breastfeeding is superior.

12. Prove it

Prove it’, also known as ‘proof by ignorance’ or ‘OMG SAUCE’, is an informal fallacy in which lack of known evidence against a belief is taken as an indication that it is true.

Allison gets this precisely backwards. The argument from ignorance is NOT an absence of evidence. The argument from ignorance is the fallacy that demands proving the negative.

In order to make a claim, you MUST prove it. Otherwise it is nothing more than your opinion.

13. Shifting the goal posts and 14. Zigzagging

Once again, the examples that Allison cites, aren’t illustrative of either shifting the goal posts or zigzagging

At the end of the list, I was left with several impressions.

First, Allison doesn’t understand logic. She routinely labels valid arguments as fallacies, and misunderstands specific logical fallacies.

Second, Allison thinks that shouting “logical fallacy” relieves her of the twin responsibilities of proving her allegation that a claim is a logical fallacy, and of addressing facts that aren’t fallacies at all.

Allison’s ultimate problem is that she has no scientific evidence to support the grossly inflated benefits of breastfeeding and the grossly inflated risks of formula feeding that she espouses. Her list is one long excuse for why she believes she doesn’t need to present scientific evidence for her claims.

That’s her biggest mistake of all.

Lactivism has a problem. It privileges process over outcome.

It is no longer enough to raise a healthy, happy, well-adjusted child who becomes a healthy, happy, well-adjusted adult. How you raise that child, specifically how you feed that child, has assumed outsize importance.

Prior to lactivism, there was no right way or wrong way to feed an infant. Properly prepared infant formula was considered no better and no worse than breastfeeding. Since the advent of lactivism, there is only one right way to feed a baby, and it is women’s ability and willingness to emulate a fantasized version of paleo infant feeding that supposedly determines whether they will be good mothers, and whether their babies will bond to them and they to their babies.

Does that sound familiar? It should because it bears great similarity to natural childbirth and homebirth advocacy.

The point of childbirth is no longer seen as having a baby, but instead, the specific process by which you have a baby has developed outsized, and in my view thoroughly misplaced, importance. Birth has become a performance. Process is privileged over outcome.

Prior to Grantly Dick-Read, there was no right way and no wrong way to have a baby. Any birth in which both the mother and baby survived was a good birth. Dick-Read, and the string of old white men who followed him (Fernand Lamaze, William Bradley, Michel Odent, etc.) changed that. Now women are encouraged to judge themselves and other women by faithfulness to a carefully scripted performance of birth: no pain relief, no C-sections, no interventions of any kind. Women have been taught that it is their ability to emulate a fantasized version of paleo-childbirth that determines whether they will be good mothers, and whether their babies will bond to them and they to their babies.

I, on the other hand, am a momivist.

What’s a momivist?

A momivist privileges people over process. Specifically, a momivist privileges mothers and what works for them and their families than over any specific process for giving birth to and raising children.

When you think about it, it is difficult to understand why women have allowed others to evaluate and render moral judgments over whether the process they are using in giving birth and raising their children is optimal. But when you consider that there is an entire industry complete with products, courses and cadres of health paraprofessionals designed to support the “correct” way to give birth and to feed and nurture children, it isn’t so surprising after all.

That industry is only profitable to the extent that it convinces women that there is a right and a wrong way to give birth or feed a baby. In order to preserve and increase their profits, they engage in massive and well funded marketing campaigns to make women feel badly about doing anything any other way but their way. In contrast, there’s not a lot of money in putting mothers ahead of process. You can’t sell books, products and courses to people who think that they can raise perfectly happy and healthy children without the guidance of moral arbiters.

It’s just an extension of the marketing principles applied to other products. Want to sell mouthwash? Convince people that without using mouthwash, they will have bad breath, and be social failures with no chance of having sex with attractive people.

What to sell natural childbirth? Convince women that without natural childbirth, they will fail at their very first task of motherhood and be unable to bond with their own children.

Want to sell lactivism? Convince people that, contrary to the scientific evidence, breastfeeding supposedly has massive benefits and formula feeding supposedly has massive risks. Make it difficult for women to obtain formula in hospitals, and, above all, shame them with threats that their formula fed children will be sick, dumb, and socially maladjusted.

Natural childbirth, homebirth, lactivism and attachment parenting privilege processes because they make money from promoting those processes.

Momivism privileges mothers over process and there’s not a lot of money to be made in telling people they are doing fine and don’t need any special products, books or courses.

Momivism, by encouraging respect for individual mothers and the personal choices of others, does not allow one mother to feel superior to another mother for parenting the “right” way.

Momivism, by recognizing that there are many right ways to give birth and raise children, deprives some women of the opportunity to publicly shame other women for not mirroring their own choices back to them.

Momivism has a lot of downsides for the industries that promote feelings of inadequacy, shame and depression, but only upsides for mothers.

Imagine a world where mothers support each other instead of tearing each other down. Imagine a world where mothering choices are judged based on the actual effect on specific children, not grossly inflated theoretical risks and benefits. Imagine a world where mothers recognize each other as having different needs, aspirations and desires and respected those differences.

We could have that world if we were all momivists instead of advocates for a preferred method of parenting.

Let me give thanks where thanks is due: Thank you homebirth advocates; I can always rely on you to do my work for me, helpfully illustrating my central claims about homebirth advocacy.

For example:

1. The narcissism of homebirth advocates

Rixa Freeze attempts to enumerates many of my claims:

Along with accusations of being selfish, narcissistic, irresponsible, horribly misinformed, or tragically brainwashed, home birthers also are accused of wanting to control their birth.

Now read the whole post (it’s very short). Does it strike you that anything is missing?

That’s right. There’s no mention of the baby! You remember the baby, the entire point of the birth for the rest of us, not a prop unworthy of mention.

But apparently not for Rixa. In a post of only 302 words, Rixa uses the words “I,” “my,” and “me” 20 times. She mentions the baby 0 times.

Just in case you had any doubts that homebirth was about anything but the mother, Rixa confirms the narcissism of homebirth.

2. Earlier this week I wrote about homebirth and defining deviancy down. Simply put, homebirth has so many bad outcomes that  advocates have been forced to redefine bad outcomes as “good.”

Case in point: in the post Grounded Midwives, Chris Brecheen raved about the homebirth midwives who attended the female partner in his polyamorous relationship.

What wonderful things did they do?

Then they started talking about the placenta.

Not if, mind you, but what should be done with the placenta. I sat there trying desperately not to bust out into a few choice lines of Tim Minchin’s Storm while they were calmly discussing encapsulation vs. placenta stew with the apprentice midwife. It was just too much.

“So, is there any science behind this placenta stuff?” I asked, knowing full well there wasn’t …

“Not even a little bit,” the midwife said in a relieved voice.

Wait, what? Was she . . . maybe . . . as uncomfortable as I was?

I watched the midwife’s eyes flick over to the apprentice—the one who was offering to do the encapsulation. The midwife bit the corner of her bottom lip a little, and then launched into a discussion about how a placebo you believe in has real power even if it is the placebo effect. “If it works, it works—even if everyone knows it’s a placebo.” …

Suddenly, I had an ally—a midwife ally who knew this placenta crap was something people believed in, took seriously, would probably get offended about, but had absolutely no science backing it.

And that’s when I realized Renee was going to be in good hands …

Wait, what? The midwife condones her assistant making money from a procedure she knows to be pseudoscience and Chris is impressed because she acknowledged that it has no benefit?

This guy has very low standards.

And that turned out to be a good thing, because his partner ended up with a C-section after 80 (count ’em, 80!) hours of labor. What did the midwives do that was so impressive?

Renee needed a midwife who could in one moment stand defiantly between her and our utterly obnoxious doctor and say, “Her hips are perfectly wide enough.” But she also needed a midwife who could, an hour later, be gracious enough to defer to modern medicine when it was time to admit that progress had stopped and exhaustion was kicking in.

Wait, what? Chris thinks it was a good thing that the midwife delayed a necessary C-section by an hour because she had absolutely no idea what was necessary or not?

The midwife and Chris’ family behaved like toddlers: “How do you know!” “You can’t make me.” And, like toddlers, they ended being wrong and having to do it anyway.

This is supposed to be impressive?

3. I’ve often written that homebirth advocates have absolutely no concept of risk. They dramatically exaggerate the risk of rare complications, and grossly minimize the dangers of homebirth. Once again, my friends at MANA (the Midwives Alliance of North America) come through for me and illustrate my point.

In a post entitled HUMANizing Birth (get it “human”), MANA gives pride of place to a startlingly stupid analogy promulgated by midwife Saraswathi Vedam. You may remember Vedam. She’s responsible for the grossly irresponsible Homebirth: An Annotated Guide to the Literature ©, which includes 66 separate citations that purport to show the safety of homebirth. But if you read each and every citation, as I did, you will find that only 3 of the 66 “citations” support the claim that homebirth is as safe as hospital birth.

Of the 66 citations:

Fully 25, more than 1/3, are not scientific studies at all
1 was never published
1 was published in a non-peer reviewed publication
1 was publicly retracted
17 do not even address the issue of homebirth safety
2 are underpowered
4 compared homebirth to a hospital group containing high risk women
12 showed that homebirth had an INCREASED risk of perinatal or neonatal death

What does Vedam have for us now?

Tell a man that he could possibly have a heart attack when making love. Then tell him that it would be safer for him to come to the hospital and make love while being monitored by a physician. Do you think a doctor coming in to take his blood pressure and monitor his heart every 10 minutes would affect his performance?

Ha, ha, ha; hospital birth is stupid. It’s no different from insisting that men have sex only in hospital. Ha, ha, ha. There’s just one teensy, weensy problem with this analogy. It is grossly misleading. The risk of a heart attack during sex is approximately 2-3/1,000,000 episodes and the natural risk of maternal death from childbirth is 10,000/1,000,000 births and the risk of neonatal death is 70,000/1,000,000. In other words, the risk of DEATH in childbirth is almost 50,000 times greater than the risk of having a heart attack during sex, and almost certainly more than a 100,000* times greater than the risk of dying of a heart attack during sex.

Apparently the point is supposed to be that if we don’t hospitalize men during sex, we shouldn’t hospitalize women during childbirth because the risk of death is only ONE HUNDRED THOUSAND TIMES HIGHER . Well, that sure convinced me (NOT)!

I found Vedam’s analogy instructive in yet another way. She, like most homebirth advocates, seems to think that childbirth is a “performance” and that any performance is necessarily ruined by scrutiny. In the first place, childbirth is not a performance and it is deeply misogynistic to suggest that it is. In the second place, most performers (actors, musicians, athletes) have no trouble performing at the highest levels when under scrutiny.

So it’s an awesome analogy except for the fact that birth is a 100,000 more likely to result in death than sex, childbirth is not a performance, and there is no evidence that scrutiny ruins performances.

4. Here’s a bit of this week’s lactivist idiocy for your entertainment pleasure. It comes from (who else?) Allison Dixley, the self-proclaimed Alpha Parent:

Question sent to me today:

“I feel awkward around formula feeders. I don’t know where to look. Is it okay to look at their baby? Is it okay to ask them why they don’t breastfeed, or when they stopped? What’s the etiquette? Any chance you could help with these questions? I’m not being weird, I’m genuinely curious.”

I’ll leave you to analyze this gem for yourselves.

 

*Edited to correct a math error.

Midwifery has a serious problem. A lot of its central claims simply aren’t supported by science.

There are two ways that midwifery theorists could address this problem. They could modify the central claims of midwifery theory (unmedicated vaginal childbirth is best, midwives provides evidence based care, obstetricians ignore scientific evidence) or they could dismiss science. They have taken the second approach with truly laughably results. Their pathetic attempts at dismissing scientific evidence extend from improperly invoking scientific theories of quantum mechanics and chaos theory, which they clearly don’t understand and which have zero applicability to midwifery, to attacks on the notion of randomized controlled trials, to rejecting rationality altogether and insisting that Including the Non-Rational Is Sensible Midwifery.

Simply put, while scientific research seeks to learn, specifically to learn how the human body works and how to maximize healthy outcomes, midwifery research seeks to justify, specifically to justify a primary role for midwives in the delivery of obstetric care and to justify the use of methods and claims not supported by scientific evidence.

Now comes the latest bit of midwifery buffoonery produced by Denis Walsh. You may remember Walsh, a professor of midwifery, as yet another in a line of old white men mansplaining the “benefits” of labor pain to women. Walsh has mangled yet another mainstream theory in a desperate effort to justify ignoring scientific evidence. His new paper, Critical realism: An important theoretical perspective for midwifery research, published in this month’s issue of the journal Midwifery, will no doubt impress other midwives (such big, fancy words!), but real scientists and philosophers would just howl.

According to Walsh:

Midwifery research has grown exponentially over the past 20 years and has been widely disseminated in a range of midwifery and obstetric journals. Research methods that are utilised are increasingly eclectic and reflect the variety of research questions addressing different aspects of childbirth. However conspicuously absent in midwifery journals has been in-depth discussion and debate about the philosophical underpinning of different research methods, though these have taken place in midwifery research texts and other health professions’ journals. The debate asks important questions about the nature of reality (ontology) and how we gain knowledge of it (epistemology). Such a focus is fundamental to research endeavour because unless the right questions are asked about the reality we are attempting to describe, explore or explain, then our knowledge of that reality will remain superficial and impoverished and is less likely to make a difference to childbirth practices and women’s experience. In addition, it can result in research that is inadequately justified, lacks internal coherence and therefore lacks wider credibility.

English translation: Midwifery research is, in large part, nothing more than crap and therefore no one takes us seriously. But even though our research looks crappy, it’s only because no one has explored the deeper philosophical underpinnings.

That’s where critical realism comes in.

What is critical realism?

Critical realism is a philosophy of the SOCIAL SCIENCES (not the natural sciences) combines a general philosophy of science (transcendental realism) with a philosophy of social science (critical naturalism) to describe an interface between the natural and social worlds.
It was promulgated by philosopher Roy Bhaskar:

… [W]hen we study the human world we are studying something fundamentally different from the physical world and must therefore adapt our strategy to studying it. Critical naturalism therefore prescribes social scientific method which seeks to identify the mechanisms producing social events, but with a recognition that these are in a much greater state of flux than those of the physical world (as human structures change much more readily than those of, say, a leaf). In particular, we must understand that human agency is made possible by social structures that themselves require the reproduction of certain actions/pre-conditions. Further, the individuals that inhabit these social structures are capable of consciously reflecting upon, and changing, the actions that produce them—a practice that is in part facilitated by social scientific research.

This may make sense in the world of social science research (although there are many other philosophers who would disagree), but midwifery claims are generally natural science claims, so critical realism doesn’t apply.

Walsh doesn’t really care about the validity of invoking critical realism in assessing the validity of midwifery research, he merely intends to use it as an excuse to ignore scientific evidence in favor of midwifery beliefs and intuitions.

Walsh does not like the scientific evidence about dystocia (stalled labor):

An example of this is the current research into dystocia, a complication of labour that is the principal contributor to caesarean section in nulliparous women. Most of the research has explored interventions to speed up labour … The methods utilised in these studies have been randomised controlled trials … [which] promises certainty in addressing the condition, based as they are on a positivist epistemology (knowledge that is always true and generalisable) … However, the incidence of dystocia and its negative consequences for women continues to rise. If researchers had grasped the limitations of their research methods by critiquing their ontological and epistemological underpinning, they might have asked different questions about the aetiology of dystocia, researched different interventions to manage it and ultimately had a greater impact on women’s outcomes and experience.

English to English translations: The large body of scientific literature on dystocia does not support midwives’ intuitions and claims about dystocia.

Never fear! Critical realism supposedly comes to the rescue:

Nine years ago, Anderson  began asking different questions about the aetiology of dystocia, suggesting some new categories – organisational dystocia (lack of continuity of care on labour wards), environmental dystocia (clinical, non-homely décor) and interpersonal dystocia (disagreements between labour ward midwives and obstetricians). Of course what she was hinting at were environmental, social and psychological effects that could impinge upon a woman’s ability to labour normally. Later, Downe and McCourt articulated the limitations of studying labour predominantly by using randomised controlled trials (RCT’s) because the theoretical foundations of trials reside in a positivist epistemology based on simplicity, linearity and certainty. However, labour does not unfold with a singular cause and effect physiology (oxytocin secretion therefore cervical dilatation) which then proceeds with regularity (cervix dilates in a constant trajectory) to end with birth at a relatively predictable point (average of 10 hours). It is a much more complex phenomenon which might more accurately be referred to as ‘orderly chaos’. Clearly, experiences like labour are impacted on by multiple factors in the physiological, psychological and social domains. Simply applying quantitative research methods suited to the controlled confines of a laboratory are not going to capture the intricacies of the uncontrolled milieu of a labour ward.

In other words, midwives don’t like what the scientific evidence shows so it’s okay if we ignore it.

Let’s leave aside for the moment that critical realism has been dismissed on its own terms by philosophers and let’s focus on the relevant facts:

1. The central claims of midwifery theory are not supported by scientific evidence.
2. Midwives have no intention of modifying cherished beliefs just because science shows they are false.
3. There is a desperate, ongoing search among midwifery theorist to justify ignoring scientific evidence.
4. A variety of theories from other disciplines, poorly understood or misunderstood by midwives, are invoke by midwifery theorists to baffle their followers with bullshit.

What should the average pregnant women take away from these bizarre, goofy theoretical justifications? It’s startlingly simple:

If you want science based care in childbirth, stick with obstetricians.

If there’s anything I’ve learned in more than 25 years of parenting, it’s that different children, even from the same family, need different things. And if there’s anything I learned from practicing medicine, it’s that there are many different ways (cultural traditions, religious traditions, family traditions) to raise children successfully.

But not for attachment parents, for whom there is only one way, their way.

I’m reminded of the famous quote from Henry Ford, describing the sale of the Model T:

Any customer can have a car painted any color that he wants so long as it is black.

In the world of attachment parenting, any mother can have any birth she wants, so long as it is vaginal, unmedicated, and “unhindered.”

Any mother can feed any baby what ever way she prefers, so long as it is breastfeeding.

Any mother can carry her child anyway she wants, so long as it is strapped to her body, not in a stroller or, heaven forfend, not carried, but placed in a playpen.

In other words, in attachment parenting, there are 50 shades, but all of them are either black of white, bad or good. Attachment parents don’t do nuance.

Hospital birth bad.

Homebirth good.

Never mind that homebirth dramatically increases the risk of perinatal death.

Cesarean bad.

Vaginal birth good.

Never mind that there are countless situations in which a C-section is the better, safer mode of birth for both baby and mother.

Bottle feeding bad.

Breastfeeding good.

Never mind that there are women who can’t make enough milk, find breastfeeding too painful, or simply prefer bottle feeding.

Epidurals bad.

Cranio-sacral therapy good.

Cribs bad.

Family bed good.

Vaccines bad.

Ground up herbs with unknown quantities of active ingredients good.

All parenting choices can be characterized as bad or good, nothing in between. There is absolutely no appreciation for the concept that what is good for one mother-child pair may need to be modified slightly or dramatically in order to be best for another mother-child pair. There is absolutely no appreciation that when it comes to parenting, there are infinite shades of all colors because there are infinite combinations of mother and child.

Why are parenting choices black or white in the world of attachment parenting? Because attachment parenting has nothing to do with parenting and nothing to do with children. It’s all about women and how they view themselves in relation to other women. There’s only black (not a good mother like me) and white (mirroring my own choices back to me).

But real parenting is about trying to meet the varied needs of many family members, within varied cultural and religious traditions, not to mention a multitude of family traditions. In the real world, there is no magic recipe for raising healthy, happy children.

In other words, in the real world, there are infinite shades of every color, not simply black and white.

In the winter of 1993, Senator Daniel Patrick Moynihan published a deeply influential scholarly paper entitled Defining Deviancy Down.

He started from the premise of sociologist Emil Durkheim that there is a maximum amount of deviance that a society can recognize before that society begins to fall apart. In order to preserve society  if deviancy rises above that level, standards will change so that behavior previously recognized as deviant is no longer considered deviant. In other words, if society is not careful about enforcing standards, standards will constantly be lowered.

Moynihan wrote about crime in New York City, but the analysis has been extended to many disparate areas, and I’d like to extend it further … to homebirth.

Homebirth as a philosophical movement is only legitimate as long as its central premise is legitimate. The central premise is that homebirth is as safer or safer than hospital birth. But as homebirth has risen in popularity, it has become glaringly apparent that homebirth isn’t safe at all. There are far too many deviations from safety, including deaths, brain damage, and other permanent injury, for anyone to rationally conclude that homebirth is safe. Therefore, homebirth advocates have been defining deviancy down, by insisting that what is dangerous is actually safe, that what is a disastrous outcome could not have been avoided, and that there is more to safety than whether the baby or mother lives ordies.

Consider:

1. The magic umbilical cord

It is common knowledge that any baby born blue, struggling to breath or not breathing at all, is a baby who has been compromised and perhaps seriously injured by oxygen deprivation. But in the world of homebirth, an appalling number of babies are born blue and struggling to breath or not breathing at all. How do homebirth advocates reconcile the purported “safety” of homebirth with the many babies born obviously suffering the effects of oxygen deprivation? Simple, they’ve redefined what it means for a baby to be born blue, struggling to breath or not breathing at all.

Instead of acknowledging that these babies are oxygen deprived, homebirth advocates have redefined blue babies to be “normal” and invoked the magical umbilical cord, which purportedly supplies copious amounts of oxygen after birth even though it wasn’t supplying enough oxygen before birth.

Voila! A blue baby is now “normal.”

2. Rejection of risk factors

Homebirth advocates often claim that homebirth is for low risk women, yet encourage high risk women (breech, twins, VBAC) to give birth at home. How does that make sense? It does if you define deviancy down an insist that what were previously considered deviations FROM normal are now merely variations OF normal. Presto-chango! Anyone can give birth at home because everyone is “low risk.”

3. The rejection of risk, aka “the dead baby card”

Homebirth advocates haven’t merely re-defined risk factors, they’ve redefined risk. Previously, when an obstetrician told a woman that she was at risk for a serious complication, she took that advice into consideration. Homebirth advocates have deliberately defined risk down, such that any risk that isn’t 100% isn’t a risk at all, just the obstetrician trying to scare the mother.

4. Any birth that doesn’t result in death is safe

We’ve recently seen this attempt to define safety down in the antics of Ruth and Jared Iorio desperately trying to pretend that Ruth’s birth involving a near death experience from postpartum hemorrhage, transfusions and a 2 day hospitalization is an example of the safety of homebirth. Ruth didn’t die, so homebirth is safe.

5. Dead babies are unavoidable

If you were naive you might think that a dead baby (or mother) was the ultimate example of a homebirth gone wrong. But now homebirth advocates have defined dead babies down, too. Whereas dead babies were previously recognized as homebirth disasters, they are now treated as inevitable deaths so that homebirth can be justified since the baby was going to die anyway.

Contemporary homebirth advocacy is a paradigmatic example of defining deviancy down.

Blue babies are now getting “enough” oxygen.
Risk factors are all variations of normal.
There is no such thing as risk.
If no one died it was a safe homebirth.
And even if the baby or mother died, it was inevitable.

The philosophy of homebirth is legitimate only so long as its central premise, that homebirth is as safe as hospital birth, is true. It can’t survive as a social movement otherwise. Since homebirth is obviously not safe, with mortality rates approaching 1000% higher than hospital birth and brain injury rates exceeding 1800% of hospital birth, homebirth advocates have been forced to define deviations from safety down, proving Durkheim correct. If we are not careful about enforcing standards for safe birth, those standards will be constantly lowered until they are meaningless, as they already are in the world of homebirth.