Yesterday I wrote about the fact that pediatricians and neonatologists do not support the empirical claims of natural childbirth and homebirth advocates. They do not think that NCB is safer for babies, healthier for babies or better for babies than childbirth with pain relief. Pediatricians and neonatologists strongly believe that homebirth increases the risk of perinatal death. Moreover, they assert that giving birth in water, far from being “gentle” or beneficial, actually poses serious risks of freshwater drowning for the baby.

I asked the question, if homebirth is safe, why do pediatricians oppose it? As far as I could tell, no NCB or homebirth advocates could answer the question.

Now I’d like to ask the corollary: is there any information purporting to show that homebirth is safe that comes from anyone other than homebirth advocates?

I don’t think so, but I’d be happy to look at any evidence that anyone would like to present. Can you find a study, a set of statistics, an international dataset that demonstrates that homebirth is as safe as hospital birth for comparable risk women that wasn’t created, collected or collated by homebirth advocates.

If you can’t find anything, and I suspect that is the case, you need to ask yourself an even more important question: if the only people who insist that homebirth is safe are homebirth advocates themselves, isn’t it time to acknowledge that homebirth isn’t safe?

I’d like to come at the homebirth issue from a different angle. That’s because homebirth advocates have created an alternate reality of internal legitimacy complete with immunizing strategies to defend against logical arguments.

This alternate reality is based firmly on the notion that obstetricians cannot be replied upon for accurate information because they fear competition from homebirth midwives. The argument is ludicrous on its face, since there is a shortage of obstetricians and homebirth is a fringe of a fringe movement that threatens no one except babies.

But lets bypass the alternate world of internal legitimacy entirely and ask the obvious questions:

If natural childbirth is better for babies, why don’t pediatricians think so?

If waterbirth is safe, why do neonataologists believe strongly that it is dangerous for babies and leads to drowning?

If homebirth is as safe or safer than hospitals, why aren’t pediatricians and neonatologists endorsing it?

The concept of an alternative world of internal legitimacy was introduced in the paper The Legitimacy of Vaccine Critics: What Is Left after the Autism Hypothesis? by Anna Kirkland, published in Journal of Health Politics, Policy and Law in October 2011. It describes vaccine rejectionists, but applies equally well to natural childbirth and homebirth advocates.

[They]have built an alternative world of internal legitimacy that mimics all the features of the mainstream research world — the journals, the conferences, the publications, the letters after the names — and some leaders have gained access to policy-making positions. Mixing an environmentally inflected critique of [obstetrics] and Big Pharma with a libertarian individualist account of health has been a resonant formulation for some years now, with support flowing in from both the Left and the Right.

NCB and homebirth advocates need to ask themselves:

If midwifery and natural childbirth journals are legitimate, why aren’t pediatricans and neonatologists citing their papers?

If NCB is better for babies, why aren’t prominent NCB advocates invited to lecture at pediatric and neonatology conferences?

The answer is obvious. Pediatricians and neonatologists recognize that the empirical claims of NCB and homebirth advocates are flat out false.

Professional NCB and homebirth advocates have long recognized that their claims have no legitimacy outside of their alternate world and have created “immunizing strategies” to deal with the scientific evidence provided by obstetricians. Therefore, they take the precaution of deploying immunizing strategies such as those described by Boudry and Braekman in their paper Immunizing Strategies and Epistemic Defense Mechanisms.

What are immunizing strategies? They are used to “immunize” true believers against the data and arguments of those who disagree. By introducing small bits of those data and arguments, professional homebirth advocates seek to train followers to ignore and discount the valid data and arguments to which they will be exposed.

As Boudry and Braekman explain:

… [A]dvocates of a theory may resort to certain generic strategies for protecting a cherished theory from mounting adverse evidence: cherry-picking the data, shooting the messenger, distorting findings, special pleading, discrediting the methods employed in research with unwelcome results, accusing the new ‘orthodoxy’ of a hidden agenda etc.

In the case of NCB and homebirth advocacy, these include the claim that obstetricians claim that homebirth is unsafe for no other reason than to reduce economic competition.

However, NCB and homebirth advocates have never taken into account the views of pediatricians and neonatologists. Precisely because there is no economic argument to make to vilify those who care for children, they’ve tried to ignore them completely. So let’s not ignore them.

If anyone knows what is safe for babies it is pediatricians and neonatologists who devote their entire professional lives to caring for babies and have no economic incentive to oppose either natural childbirth or homebirth.

Yet pediatricians and neonatologists do not endorse NCB or homebirth and categorically reject most of empirical claims about the purported benefits of NCB and the purported safety of homebirth.

Every NCB and homebirth advocate needs to ask herself the obvious:

If pediatricians and neonatologists can find no benefit of NCB for babies, why should I believe that there is any benefits?

If pediatricians and neonatologists strongly believe that homebirth increases the risk of perinatal death, why should I believe it is safe?

Can you imagine someone declaring: “A successful kidney transplant isn’t enough. I am devastated that my doctor did not agree with my assessment that I could have had my kidney inserted laparoscopically and thereby avoided that big scar in my side.”

Cna you imagine someone declaring: “A cure of my colon cancer isn’t enough. My doctor should have listened to me when I suggested that herbs would work just as well as chemotherapy.”

Or how about someone insisting: “Successful anesthesia for my appendectomy isn’t enough. I wanted enflurane, dammit, but my anesthesiologist gave me something else.”

I can’t imagine it, and I bet most of you can’t either. So why do some women say, as Christen of ImprovingBirth.org does:

We hear all the time, “a healthy baby is all that matters.” That’s simply not true—especially when, all too often, “healthy” simply means “surviving birth,” for both moms and babies. That’s not nearly good enough.

Why would someone make such a statement and why are they very wrong to do so?

Self-described birth activists make claims like this for one major reason, they are ignorant of the single most important thing anyone providing care to pregnant women needs to know: Childbirth is inherently dangerous. It only looks safe because liberal use of the interventions of modern obstetrics has made it safe.

Why don’t they know this? They have been indoctrinated by a group of people whose interests are met only by denying the inherent dangers of childbirth. It started with Grantly Dick-Read who wanted white women of the “better” classes to have as many children as possible; acknowledging that birth kills mothers and babies wouldn’t help achieve that aim. It has been perpetuated by a group of women who make their money (and build their fragile self-esteem) by pretending that their dreadfully inadequate training as midwives, doulas and childbirth educators is “enough” since nothing is going to go wrong.

Indeed, as I wrote about yesterday, major childbirth organizations like Lamaze don’t even bother to mention the most dangerous pregnancy complications or to educate women how to recognize them. The same people who piously bleat about maternal mortality don’t do a single thing to prevent the disaster that they claim to care so much about.

Obviously, if you are ignorant about the fact that childbirth is inherently dangerous and that it only seems safe because of modern obstetrics, you are going to have a low threshold for complaining about anything that ruins your perfect birth fantasy, but there’s more to it than that.

Natural childbirth advocates demand respectful care, but don’t seem to understand what respectful care entails. Christen says:

The truth is that in this day and age and place, a higher standard can and should exist: a healthy baby, a healthy mom, and a positive, respectful, family-centered birth experience for everyone.

Most hospitals have nicely decorated labor and delivery suites, perks for new parents and are extremely solicitous of siblings and other family members. So when NCB advocates complain about lack of respectful, family centered care, they are referring to something entirely different than respectful family centered care.

They are referring to unmedicated vaginal delivery with no interventions at all. Respectful care is perfectly consistent with using every possible obstetric intervention. Family centered care is completely consistent with epidurals and C-sections. Since respectful, family centered care has absolutely nothing to do with unmedicated vaginal delivery, how did NCB advocates come to conflate the two?

They do so because they have a very idiosyncratic view of respect. For them, respect means boosting their self-esteem by pretending they are educated about childbirth when in reality they are ignorant. It means collaborating in the delusion that “trusting” birth has anything at all to do with safe birth outcomes when, of course, it is meaningless. It means acknowledging dangerous choices as wise and lies as truth.

Ironically, they have no respect at all for obstetricians. They denigrate their knowledge; they equate caution with fear-mongering; and they are absolutely sure that C-sections are done for no better reason than doctors wanting to get to their golf games.

Can you imagine a kidney transplant patient insisting that he or she knows more than the transplant surgeon? Can you imagine a cancer patient insisting that her oncologist is recommending chemotherapy because he likes to play the “dead person card”? Can you imagine a surgical patient insisting that anesthesiologists choose one anesthetic over another so they can get to their golf games more quickly?

Most people would consider such behavior presumptuous, misguided and needlessly provocative, but when face with an obstetrician, NCB advocates label such obnoxious behavior as laudatory.

Contrary to the beliefs of NCB advocates, there is nothing respectful about a doctor pretending you are right when you are wrong. There is nothing respectful about pretending that vaginal birth is an achievement when most of the women who have ever existed have done it (or died trying). There is nothing respectful about pretending that there are medical benefits to avoiding pain relief in labor when there aren’t any.

NCB advocates aren’t looking for respect. They are looking for validation. That’s fine, but they should stop pretending that validating ridiculous beliefs is respectful. And it might be helpful if they showed even a modicum of respect to their obstetricians in turn.

In the wake of a Downton Abbey episode in which a main character lost her life to eclampsia, Lamaze has suddenly discovered it.

The recent episode of “Downton Abbey” brought much needed attention to the maternal health issue of pre-eclampsia. Why is it we rely on fiction for permission to get real? … How do we encourage each other and the next generation of maternal health advocates to harness the undeniable power of media but not become part of a social construction of maternal mortality as not real?

Why do we rely on fiction? Because organizations like Lamaze refuse to discuss pregnancy complications.

According to The Pre-eclampsia Foundation:

Thousands of women and babies die or get very sick each year from a dangerous condition called preeclampsia, a life-threatening disorder that occurs only during pregnancy and the postpartum period. Preeclampsia and related disorders such as HELLP syndrome and eclampsia are most often characterized by a rapid rise in blood pressure that can lead to seizure, stroke, multiple organ failure and death of the mother and/or baby.

Pre-eclampsia can come on silently. That’s because the leading symptom is high blood pressure and most women have no idea their blood pressure is high unless it is measured. Other signs include swelling, protein in the urine and hyperreflexia (exaggerated reflexes in response to testing with a reflex hammer). Complications of pre-eclampsia include seizures (which means that the dsease has progressed to eclampsia), stroke, liver abnormalities, destruction of red blood cells and lack of platelets.

Pre-eclampsia is more common in first pregnancies, but can happen in any pregnancy. Since the disease is extremely serious, relatively common, and poses a risk to all pregnant women, you would think that any organization or author purporting to advise women on healthy pregnancy and childbirth would mention and then emphasize the signs and symptoms of pre-eclampsia. You would be wrong.

Consider Lamaze International. On their entire website, I could find not a single page devoted to one of the major killers of women and babies. Indeed, rather than educating women about pregnancy complications, Lamaze downplays complications into invisibility.

An evolving body of research repeatedly shows the danger of interfering without a valid reason in the natural processes of pregnancy, birth, and breastfeeding. Any intervention, no matter how simple it seems, may disrupt the normal process and create problems that, in turn, must be managed with more interventions. All interventions have side effects that can be risky for both mothers and babies.

Actually, they go further than that by giving the back of the hand to the majority of prenatal tests.

Many of these newer tests were created to diagnose problems in high-risk pregnancies. But with the increased medicalization of pregnancy, they have become routine for healthy women with no known risks. This does not mean that every test is right for everyone, however, or that they are risk-free themselves. There may be a problem that prenatal testing doesn’t show, or a problem may not exist even if the test suggests it does. Results that are unclear or even misleading can plague your peace of mind and decrease your confidence. The barrage of tests can also make you feel like your health-care provider knows everything there is to know about your pregnancy, which is not the case.

Lamaze is not alone. Henci Goer wrote a 500 page book entitled Optimal Care in Childbirth. How many pages did she devote to pre-eclampsia and eclampsia. Zero!

In both cases, the neglect of pre-eclampsia is inexcusable, but it could be worse. Many natural childbirth and homebirth advocacy books and website peddle the lie that pre-eclampsia can be prevented with diet? There is not a shred of scientific evidence that diet has any impact on pre-eclampsia but that doesn’t stop NCB and homebirth advocates from blaring dangerous falsehoods.

Why won’t NCB organizations and authors even mention pre-eclampsia until forced to do so by a fictional television program. I suspect three reasons:

1. There is no money to be made by midwives, doulas and childbirth educators from women who have pregnancy complications. All three ignore anyone who isn’t likely to pay them.

2. Natural childbirth rests on the bedrock lie that childbirth is inherently safe. Childbirth is actually inherently dangerous and pre-eclampsia/eclampsia is one of the reasons why; therefore, it must be ignored.

3. NCB advocates fetishize process over outcome. The ultimate birth for an NCB advocate is one that involves no interventions, not one that results in a healthy baby. Pre-eclampsia “ruins” NCB perfection; better to pretend that it doesn’t exist.

The Science and Sensibility piece which discovers pre-eclampsia includes an interview with a volunteer at The Pre-eclampsia Foundation. Asked what she would recommend to childbirth educators and doulas, Jennifer Carney answers:

Really, I think it comes down to trusting that the moms you are helping can handle the information that they NEED to know. I was alone. If I had known that these symptoms could mean eclampsia or preeclampsia, I might have been able to save myself from the seizures – which would have also likely saved me from the ARDS and pneumonia. My ICU stay might have not happened. My son was going to be born early – but if I had gone to my doctor or called an ambulance myself, it might not have been so close a call. It’s not my fault that I didn’t know – but it could have been tragic.

Know the signs and symptoms. Know that a woman with severe PE might be having cognitive issues – confusion, and vision problems. Don’t ask her to drive. Don’t downplay distress. And take complaints of headaches, upper quadrant pain, nausea, diarrhea, shoulder pain, visual disturbances, and a general feeling that something is “off” seriously. And if you have a client or patient that experiences something like this, please follow up and ask about mental health issues. Be careful not to ask questions that can be answered with the words: “I’m fine”. Dig deeper.

Pre-eclampsia/eclampsia is a killer of women and babies. It is not uncommon, and it can be easily diagnosed by basic testing. While women cannot diagnose pre-eclampsia themselves, there are signs they can look for and bring to the attention of their providers before pre-eclampsia turns deadly. Of course they can only do that if they know about pre-eclampsia.

It is a damning indictment of NCB organizations like Lamaze that they downplay and ignore common, life threatening pregnancy complications. If you can’t rely on them to provide basic information to save the life of a pregnant woman, you can’t rely on them for accurate information on anything.

Here’s the homebirth website,
Here are the people,
Open the homepage,
Look at the sheeple.

“Sheeple” is a derogatory term thrown about by homebirth and natural childbirth advocates to imply that women who consult and heed the advice of obstetricians are blind, unthinking followers. However, when it comes to sheeple, homebirth and NCB advocates have it precisely backward. It is they who are sheeple, blindly following leaders of the cult like homebirth and NCB movements, lacking the knowledge base to question the lies they are told, and putting the lives of their babies at risk for no better reason than bragging rights.

Consider the following comment, typical of the homebirth advocates who regularly parachute into the blog to chastise and “educate” the rest of us:

Babies Die. It happens in hospitals and it happens at home or in transit. The only difference is that the world looks down on you if your baby died during a homebirth. Then it turns from pity to the fact that you deserved to have your baby die because you chose to have them at home. That attitude does nothing to bridge the gap between home birth and hospital birth. After reading your blog for a few days now, I have come to the conclusion that you are just as harsh, in your face, and rude as you claim all the homebirth advocates to be. This kind of behavior only feeds the hate that is out there already. You posting pictures that were taken from a website in which parents gather together and post to help support each other and then use it to say “SEE! I Told You So.” is truly disgusting. There seems to be nothing sacred to you and people like you. You are all correct and everyone else is wrong.

I’ve seen these sentences, in a various combinations, literally thousands of time. They are lifted wholesale from homebirth and NCB websites and message boards where the ignorant inspire other ignorant women to believe nonsense. I would hope that anyone with a modicum of intelligence would learn to question the nonsense, but they rarely do. That’s because they are not independent thinkers; they have no original ideas. They lack even the most basic knowledge of science, statistics and childbirth to make any independent assessment of anything. They are cult members hoping to enhance their reputation among other cult members.

Let’s parse the comment for the components of their foolishness.

1. Babies Die. It happens in hospitals and it happens at home or in transit.

Duh. Of course babies die. Childbirth is inherently dangerous. The issue is not that babies die in both places but how the rates of death compare. Homebirth advocates have a serious problem with basic arithmetic. Apparently most of them were day dreaming in the 4th grade when they were supposed to be learning abut rates.

Approximately 12 people die from poisonous snake bite in the US each year. Approximately 520 women die from pregnancy and childbirth related causes each year. By the “reasoning” of homebirth advocates, pregnancy is more than 40 TIMES more dangerous than poisonous snake bites. Wow, who knew that pregnancy was so dangerous?

What’s wrong with this “reasoning”?

Comparing absolute numbers is inappropriate. The only valid comparison is that of rates. Rate, in this case, is the absolute number of people who died from the cause divided by the number of people who could have been exposed to the cause. Approximately 8,000 people are bitten by venomous snakes each year for a death rate of 1.5/1000. Approximately 4 million women are pregnant each year, for a death rate of 0.13/1000 (equivalent to 13/100,000). In other words, snake bite is 12 times more dangerous than pregnancy.

2. The only difference is that the world looks down on you if your baby died during a homebirth.

No the difference is that most babies who die at home did not have to die. They died for lack of access to life-saving emergency procedures (like C-sections) and personnel (obstetricians, anesthesiologists and neonatologists) who could have saved them. Babies who die in the hospital probably would not have lived regardless of where they were born because they die in spite of access to life-saving emergency procedures.

It’s the difference between babies who die in car accidents because they weren’t buckled into carseats and babies who die despite being buckled into carseats. That babies die in both situations does not change the fact that buckling a baby into a carseat means taking every precaution, while letting your baby sit unsecured in a moving car is the height of irresponsibility.

3. That attitude does nothing to bridge the gap between home birth and hospital birth.

So what? My attitude does nothing to bridge the gap between women who secure their babies in carseats and women who don’t, either. I’m not trying to “bridge the gap”; I’m trying to introduce homebirth advocates to the dangers of homebirth through the use of basic logic, basic statistics or stories and pictures that bring the death toll of homebirth into vivid view.

4. This kind of behavior only feeds the hate that is out there already.

Do you think I care? Your “hate” is like the “hate” of my children when they were small and didn’t get their way. I’m not here to have you like me. I’m here to force you to face unpleasant truths, and give up comforting lies. The fact that people hate me simply emphasizes their dread that I am right and they risked or even sacrificed their babies’ lives for no better reason than an experience.

5. You posting pictures that were taken from a website in which parents gather together and post to help support each other …

Proving yet again that homebirth advocates can’t be bothered to read simple English before leaping to conclusions. The Hurt by Homebirth website is MY website, created in response to requests from homebirth loss parents who selflessly share their pain so no other parent has to walk in their shoes. How did the commentor “know” what I had supposedly done. Some other homebirth advocate told her and she believed it unquestioningly.

6. You are all correct and everyone else is wrong.

No, I, in my capacity as an expert with decades of training, experience and command of the obstetric literature are much more likely to be correct than homebirth advocates who are a fringe group full of women lacking basic knowledge of any relevant discipline. I represent the overwhelming majority of obstetricians, of doctors of all specialties and of American women who would never risk the life of their babies on the say-so of the icons of the homebirth movement, who speak mostly nonsense.

My blog is a testament to the fact that women who choose hospital birth recognize the value of professional expertise, but are also eager to learn and capable of reading the scientific literature, debating the merits of various points of view and holding a self-image strong enough to withstand even the most vile comments of homebirth and NCB advocates.

Who are the real sheeple? Homebirth advocates, of course, who believe things not because they make sense or because they are said by experts by because they choose to unthinkingly follow the nonsense of other lay people as ignorant as themselves.

ATTENTION PARENTS AND FUTURE PARENTS! Homebirth advocates and homebirth midwives do not want you to know about the incredible fear and horror you and your baby may feel during homebirth, or the soul crushing grief and guilt you may experience for the rest of your life because your baby was permanently injured or died, all because you believed the crap spewed forth on websites like Birth of a New Earth.

The following photos comes from Hurt by Homebirth, a website that exists for the sole purpose of allowing homebirth loss mothers to tell their stories.

The world of homebirth advocacy is a vast echo chamber where ignorant women praise other ignorant women for being “educated.” It is a world where fragile women go to boost their self-esteem with unrestricted plaudits for even the most irresponsible decisions. It is a world where women actually risk their babies’ deaths for the admiration of their equally uneducated peers.

In other words, it is not the real world.

Perhaps that explains why homebirth advocates react with utter incredulity when the real world gets involved.

They are shocked, shocked to learn that when they publish their stories of loss, or neonatal injury to the entire population of the world, other people read them. Why don’t they keep them private? Because they are seeking praise and validation for the irresponsible decisions that led to the deaths or injuries of their babies. Evidently, the praise and validation they get from the homebirth advocates that they know personally is not enough. They need more and they actually think they will get it by telling the entire world of their choices and the hideous outcomes.

They cannot believe that there could be any other response to a homebirth loss or injury than praise for the mother who is now bereaved or facing permanent injury to her child, often as a direct results of her own decisions. That, despite the fact that the mother has often been begged by her parents, in-laws, and friends to give birth in a hospital where lifesaving equipment and the personnel who know how to use it are available.

Occasionally, they react the way that any sensible person would, and make their blog private. Generally, they do not, because you can’t get praise from strangers if they aren’t able to read your story.

Here’s what they need to keep in mind:

The overwhelming majority of people think that homebirth is irresponsible. They aren’t impressed with your decision; they are appalled. They don’t think you are educated; they think you are ignorant. They are very sorry that your baby died or was injured, but they think you bear some, if not all, responsibility for the tragedy that didn’t have to happen.

If you don’t want to know what the majority of people think about your choice, don’t publish your story to the entire world. No one is going to respect your “privacy” when you clearly have no respect for it, eagerly abandoning privacy in a desperate attempt to gain validation.

Harsh? Maybe, but that’s nothing compared to the suffering of the babies whose lives were sacrificed unnecessarily or who will have to live with permanent brain impairment or other injury.

An ongoing discussion in my Facebook group about the reliability of specific scientific papers purporting to show the benefits of natural childbirth reminds me yet again that most people are deeply confused about statistics.

For laypeople, part of the problem is the fact that the word “statistics” has more than one meaning. Used colloquially, statistics can refer to data. The technical meaning of the term is different. According to the American Statistical Association:

Statistics is the science of learning from data, and of measuring, controlling, and communicating uncertainty …

Statistics can be divided into descriptive statistics and inferential statistics. Descriptive statistics are, as the name implies, descriptive. A classic example of descriptive statistics is an average. If someone drives 10 miles an hour for 1 hour, 20 miles an hour for 1 hour and 30 miles an hour for one hour, the average speed is 20 miles an hour. Descriptive statistics are extremely useful, yielding everything from RBIs in baseball, to class medians in college courses, to standard deviations that allow us to determine how much a specific result differs from the majority of results.

When we talk about scientific papers, however, we are referring to inferential statistics. Once again the name is apt. Inferential statistics allows us to make predictions about large groups or populations by looking at a small subset. For example, we might look at the long term outcomes of smoking among 10,000 people in order to make predictions about the impact of smoking on the tens of millions of people who smoke. The key value of inferential statistics is that it tells us which observations can be extrapolated to large populations and which cannot.

Most individual observations cannot be extrapolated to large populations because they represent a random result. For example, you might meet a woman named Esmerelda who has five daughters. You cannot infer from that that all women named Esmerelda will have five daughters, will have only daughters or will have children at all. And that brings us to the first and most basic element of inferential statistics. You must have collected a large group of individual observations before you can extrapolate to the general population. Why? Because inferential statistics tell us that unless we prove otherwise, any set of observations is likely to reflect random variation, and will not be reproduced in another set of similar observations.

How many individual observations do you need before you can draw an inference from a data set? The answer can be determined by statistical power, which is short hand way of identifying the power of a set of observations to yield an accurate prediction about any population. Consider coin tossing. Imagine that you toss a coin 6 times and it lands heads 2 times and tails 4 times. Can you infer that tossing a coin results in heads 1/3 of the time? No you cannot, because the result you obtained was purely random. You need many more observations for the study to have enough power to yield an accurate inference. If you tossed a coin 2 million times and got heads 999,999 times and tails 1,000,001 times, you would be entitled to infer that coin tosses yield heads half the time and tails the other half.

Determining whether a study includes enough observations to draw inferences is beyond the scope of this post, but, as a general matter, the less likely you are to see a specific result, the more observations you need to reach valid conclusions. If a study looks at neonatal deaths at homebirth, and neonatal deaths are typically measure per 1000, you are going to need several thousand observations or more to draw valid conclusions. There are exceptions to this rule, since it isn’t the number of observations alone that determines whether a study is adequately powered. However, as a general matter, if a study contains only a few dozen observations, it is underpowered and you cannot make ANY inferences regarding the results.

Most midwifery studies are grossly underpowered. If you look at the C-section rates among 20 women who employed doulas during labor and compared that to the C-section rate of 20 women who did not employ doulas, you can generate descriptive statistics such as the average C-section rate in each group. However, you cannot draw ANY conclusions about the impact of doulas on C-section rates, because the few observations you have generated are not necessarily representative of a real difference in C-section rates caused by employing a doula. When a study is underpowered, the results are simply random and tell us nothing.

A second basic element of inferential statistics is statistical significance. A study may be adequately powered, yet the results may still be insufficient for us to draw conclusions. Consider a study that compares the neonatal death rate of 10,000 women who had homebirths with 10,000 women who had hospital births. Suppose that 11 babies in the homebirth group died and 10 babies in the hospital group died. Does that mean that homebirth is 10% more dangerous than hospital birth. No, it doesn’t not, because although the results of the two groups are different, performing the appropriate statistical test will show that the difference is not statistically significant. Determining which is the correct test of statistical significance and performing it can be complicated, but the underlying concept is simple. When a result is not statistically significant, it means that it is likely that it happened by random and therefore does not reflect a true difference. If a result is not statistically significant, the result has no predictive value. In other words, it is meaningless.

A third basic concept of inferential statistics is that you must be sure that you are comparing like with like. Suppose you are comparing breastfeeding rates at a hospital with the “baby friendly” designation to one that lacks the designation. In order to draw a valid conclusion, you must be sure that the women who give birth at the baby friendly hospital are similar to the women who give birth in the other hospital. If it turns out that the baby friendly hospital is located in a wealthy suburb, where almost all the women are married, well educated and relatively well off and the hospital that is not baby friendly is in the inner city, serves a population of teen mothers who are uneducated and impoverished, you are not going to be able to draw any conclusions about whether the baby friendly designation improves breastfeeding rates even if the baby friendly hospital has a statistically significant increase in rates and even if the study is adequately powered. That’s because there are other factors, known as confounding factors, that may be responsible for the observed difference and the baby friendly designation may have nothing to do with it at all.

Obviously this is a grossly oversimplified view of inferential statistics, but it does suggest several things that lay people can look for when trying to determine if the conclusions of a study are valid.

Does the study involve lots of people in each group? If not, the study is underpowered and the results are meaningless.

Are the differences between the two groups statistically significant? If not, the results are meaningless.

Did the authors compared groups that are similar except for the one variable under investigation? If the two group differ appreciably, the results are meaningless.

Just by looking at these three factors, lay people can easily discard much of the homebirth and natural childbirth literature as invalid.

A new study of birth centers, published yesterday, is being hailed by midwifery advocates. While it does demonstrate that giving birth in birth centers accredited by the American Association of Birth Centers is safe, it does NOT show that birth centers have a lower C-section rate than hospital care for comparable risk women, and therefore, it does NOT show that increasing birth center births would save millions of dollars.

The study is Outcomes of Care in Birth Centers: Demonstration of a Durable Model, by Stapleton, Osbourne and Illuzi.

The study found that birth in accredited birth centers was very safe:

There were no maternal deaths. The intrapartum fetal mortality rate for women admitted to the birth center in labor was 0.47/1000. The neonatal mortality rate was 0.40/1000 excluding anomalies.

This is comparable to death rates for low risk hospital birth.

So far, so good. Then the authors, in their efforts to promote birth centers, go far beyond the data. They claim:

The cesarean birth rate in this cohort was 6% versus the estimated rate of 25% for similarly low-risk women in a hospital setting.21 Had this same group of 15,574 low-risk women been cared for in a hospital, an additional 2934 cesarean births could be expected. The Medicare facility reimbursement for an uncomplicated cesarean birth in a hospital in 2011 was $4465.49 Given the increased payments for facility services for cesarean birth compared with vaginal birth in the hospital, the lower cesarean birth rate potentially saved an additional $4,487,524. In total, one could expect a potential savings in costs for facility services of more than $30 million for these 15,574 births.

But the C-section rate for comparable risk births in the hospital is NOT 25%. It is far lower, in the range of 4-8%. Indeed, I’m not sure where they even got their estimate of a 25% C-section rate for comparable risk births since does not appear in the reference specifically cited to support this number.

The first rule of scientific comparisons is to compare like to like. Therefore, when looking for the appropriate comparison group for women who give birth in accredited birth centers, we must restrict the group to low risk women, with single babies, at term, without intrauterine growth retardation. Furthermore, we must exclude from the comparison group any women who have pre-existing medical problems or pregnancy complications, since they would be excluded from delivering at the birth center.

In addition, we must take into account that women choose to deliver in a birth center are a self-selected group who differ markedly from the general population. They are more likely to be white, married and well educated and they are far less likely to smoke, drink alcohol or be obese.

What is the appropriate comparison group? It’s women who choose to deliver in the hospital with a CNM. There are a number of studies performed in the past 2 decades that look at outcomes for women who delivered with CNMs in a hospital. The C-section rate in that group ranges from 4-8%. Moreover, women who give birth in the hospital have access to pain relief, something that most women want.

There is no particular benefit to delivering in a birth center with a CNM as compared to delivering in a hospital with a CNM. There’s no decrease in C-section rate, and no savings from C-sections that were avoided. If the same group of 15,574 low-risk women had been cared for in a hospital by CNM, an additional 2934 cesarean births would NOT have been expected. Indeed, no additional C-sections would have been expected.

So while this paper makes an excellent argument for the safety of accredited birth centers that employ strict eligibility criteria, it does NOT show that birth centers reduce the C-section rate or save money by doing so.

Homebirth advocates have a terrible propensity for promiscuous use of language. By that I mean the use and abuse of language for the express purpose of drawing attention. Such is the case with the use of the term rape as in the currently fashionable accusation of “birth rape”. It’s not rape, it has nothing to do with rape, and it is a grievous insult to those women who have experience the horror of rape.

Even homebirth advocates recognize that abusing the term “rape” in this way is not winning friends for their cause. Hence, the latest iteration of “the obstetrician didn’t do exactly what I wanted” is “obstetric violence.” Apparently, if you are a homebirth advocate, having your feelings hurt is the equivalent of “violence.” That, of course, is ridiculous.

However, there is such a thing as obstetric violence and it is perpetrated by homebirth advocates on babies.

Babies do not ask to be conceived. If a woman decides to conceive a baby and carry it to term, she has a moral obligation to care for the health and well being of that baby. She has a moral obligation to feed it and change it, and clothe it, and put it in a carseat when she takes the baby with her to the grocery store. She also has a moral obligation not to risk its life.

Obstetric violence toward babies involves real violence, injury and death, not hurt feelings. Over the years I have written about women whose babies have died hideous deaths at homebirth.

These include breech babies whose heads were entrapped while their bodies dangled outside their mother’s vagina, and who died long before they could reach medical help.

They include babies who struggled for hours and suffocated, dropping dead into the hands of unsuspecting homebirth midwives who didn’t appropriately monitor their heart rates.

They include babies who slowly lost brain cells because their heads had delivered, but their shoulders became entrapped.

They include babies who died when they were suddenly extruded into their mother’s abdomen when a uterine incision ruptured and they bled to death long before they could reach a hospital.

They include babies who survived but suffered serious brain injuries leading to lifelong disabilities affecting their ability to move, to reason, to live on their own, to fulfill the potential that they had when labor started.

Who cares about the obstetric violence perpetrated on these babies?

Certainly not homebirth midwives, who never met a risk they couldn’t label as a variation of normal.

Certainly not homebirth advocates, who never heard of a homebirth death that they couldn’t rationalize with the all purpose, and incredibly ugly claim that “some babies are just meant to die.”

Who cares about the obstetric violence perpetrated on these babies? Obstetricians of course. You know, the people who “play the dead baby card” because they are actually worried that your baby could die.

As far as I’m concerned, there’s something very wrong when women claim that hurting their feelings is “violence. There is something very wrong when letting a baby suffocate to death, half the body born, and half still inside the mother is dismissed as inevitable, especially when it was not. And there is something very wrong when the obstetrician cares more about whether your baby lives or dies than you do.

Stop obstetric violence toward babies … have a hospital birth.