You have to give American University assistant anthropology professor Adrienne Pine credit for attempting to divert everyone from the real issue. Instead of accepting blame for her unprofessional behavior, Pine has decided to pretend that this is a referendum on public breastfeeding.

The story is straightforward. According to the Washington Post:

Adrienne Pine was in a jam. The assistant anthropology professor at American University was about to begin teaching “Sex, Gender & Culture,” but her baby daughter woke up in the morning with a fever. The single mother worried that she had no good child-care options.

So Pine brought her sick baby to class. The baby, in a blue onesie, crawled on the floor of the lecture hall during part of the 75-minute class two weeks ago, according to the professor’s account… When the baby grew restless, Pine breast-fed her while continuing her lecture in front of 40 students.

Now Pine finds herself at the center of a debate over whether she did the right thing that day and what the ground rules are for working parents who face such child-care dilemmas.

Pine behaved inappropriately. As just about every other professional woman in the world knows, the solution is NOT to bring the child to the office/operating room/construction site. The solution is to have childcare back up. Women doctors, lawyers, and general contractors have managed to figure it out. There’s no reason why we should not hold Pine to the same standard.

Pine, of course, refuses to accept responsibility for her unprofessional behavior. Instead she claims persecution.

Pine’s piece in the political newsletter Counterpunch is self indulgent, even by the standards of academia, with the overheated title: The Dialectics of Breastfeeding on Campus; Exposéing My Breasts on the Internet

Obfuscatory language? Check.
Sexuality? Check.
Neologisms? (Exposéing is not a word.) Check.
Completely missing the point? Check.

No, Professor Pine, the point is not your breasts, no matter how much you wish it were. The point is that infants do not belong on the job.

A week ago Tuesday my baby woke up with a fever. It was the first day of my intro “Sex, Gender Culture” class with 40 students and a new TA. Cancelling did not seem like an option. A friend who was visiting from Chile said to me over breakfast, “Just take her to class. You’re a working parent. Your students won’t care. It’ll be a teachable moment.”

No, it’s not a teachable moment. It is banal reality of parenting. Children get sick. Therefore, professional women must have emergency childcare plans for children who get sick. There isn’t a professional woman alive who does not know this and does not plan for it. There are even emergency childcare programs that exist specifically for this purpose. I’m not sure why, Professor Pine, you think you are an exception to this standard of professional responsibility.

As much as you’d like to portray this as a gloriously transgressive act, it is as simple and as mundane as failing to live up to your professional responsibilities. At the current rate of tuition, students (or their parents) are paying approximately $5000 to take your class. They are expecting your full attention and to be able to give their full attention to you. That’s not what they got:

I sped through the lecture and syllabus review with Lee, dressed in her comfiest blue onesie, alternately strapped to my back and crawling on the floor by my feet. The flow of my lecture was interrupted once by “Professor, your son has a paper-clip in his mouth” (I promptly extracted it without correcting my students’ gendered assumptions) and again when she crawled a little too close to an electrical outlet…

Still missing the point, Professor Pine. The point is that students had to watch your baby to make sure that she did not harm herself, not your “daring” move in dressing her in blue.

Would a judge hearing a criminal trial would be able to focus on her professional responsibilities if her baby were crawling around the courtroom? Doesn’t she owe the plaintiff, the defendant, the jury and the lawyers her full attention?

Would a surgeon removing a cancerous tumor be able to focus on her professional responsibilities if her baby were crawling around the operating room? Doesn’t she owe the patient her full attention?

Their children get sick, too, Professor Pine, and somehow they manage to fulfill their professional responsibilities without bringing their children into the workplace.

Let me make this very clear: the fact that you breastfed your child in class is not the problem, as much as you wish it were. The problem is that you brought your child to class in the first place, instead of having emergency childcare backup plans and putting them into effect.

Oh, and one more thing. Your behavior toward a student journalist (both in person and in print) is reprehensible.

I wasn’t able to get my point across. Heather continued hounding me, as my voice became increasingly hoarse and pained. I, unfortunately, was in professor mode, too polite to tell her to go to hell…

Why should she “go to hell” for doing her job?

Stop trying to portray yourself as a martyr for the cause, Professor Pine. The situation is very simple and it has nothing to do with your breasts.

You didn’t meet your professional responsibilities and you owe your students an apology as a result. Don’t claim discrimination, don’t blame your students for their “gendered” expectations, and don’t defame the student journalists who were simply reporting on the story.

The unalterable bedrock of natural childbirth advocacy is that women should refuse effective pain relief in labor. The “ideal” situation is for women to embrace their pain and pretend that it is “good pain” or “pain with a purpose.”

Of course, there is no such thing as “good pain”: NCB advocates just made that up. The pain of contractions and the pain of vaginal distention do not differ in any way from any other kind of pain. It is not carried by different nerves, it is not conducted through the action of different neurotransmitters, it is not routed to different areas in the brain. It is exactly the same as any other kind of pain. So the take home message of NCB is that the excruciating pain of childbirth should be ignored.

How about the “purpose” of the pain? Does childbirth with pain have any advantages over childbirth without pain?

I thought I might find the answer in this blog post, Natural Childbirth: Pain With Great Purpose. Amanda, the author, had a child with an epidural and then a child without an epidural. I was curious to learn how forgoing the epidural improved things. Maybe it made the labor easier; maybe the baby is healthier, maybe the baby is smarter. What does Amanda tell us?

The Pain Prepares You

When a women starts to feel contractions, the dull ache is a signal that it’s not just another day. When I felt I was in labor, it gave me time to gather up the things I needed and to make sure the support I needed was there. I also made sure to not to overexert myself that morning, to lazy around, take many showers and relax.

More importantly preparing myself mentally, physically and emotionally helped prepare me in a different way compared to my first medicated birth…

Really? But she didn’t forget to go to the hospital for her first baby. She didn’t think that the day her first child was born was just like any other. She didn’t forget to gather up the things she needed. I don’t know what she means by the claim that the pain help her prepare mentally. Did she forget to bring home her first child because the labor was painless?

The Pain Protects You

While I was in labor, the pain from contractions made me move, a lot. I was on my feet for most of the day. I walked outside, inside, upstairs, downstairs. I took a shower and then walked some more. When I did lay down to rest, my left side was more painful to lay on, so I laid on my right. All of my actions that day eased the pain a bit and helped me get from one contraction to the other.

This movement protected my body as well as my daughter’s…

How did it protect her? She doesn’t report any injury due to lack of pain at her first delivery, so what was she protecting herself against?

The Pain Provides Natural Relief

Coping with pain during labor allows the body to increase oxytocin release, which in turn causes more effective, stronger contractions. This ultimately leads to the release of endorphins, a natural narcotic. Endorphins are endogenous opioid peptides that function as neurotransmitters (say that 5 times fast)…

Aside from that being a bunch of baloney, how, exactly did that change anything. While she had a functioning epidural the first time, she had no pain. When she didn’t have an epidural with her second child she had lots of pain. It doesn’t sound like endorphins are remotely as effective as an epidural.

The Pain Helps You Respond

When I used drugs with my first birth it disrupted what I should have been doing to have an efficient labor. I know this only because I experienced what labor was like without medication. There is no way in hell I would have laid on my back for 6 hours straight if I was having a natural birth. Laying down is not effective at getting a baby out, whether using drugs or not.

So did the first baby fail to come out? Apparently not. So how can she say that laying on her back was ineffective at getting the baby out if the baby came out just fine?

Let’s summarize:

Amanda didn’t forget to go to the hospital for her first baby. She didn’t think that the day her first child was born was just like any other. She didn’t forget to gather up the things she needed. She didn’t forget to bring home her first child because the labor was painless. So how exactly did the pain “prepare” her?

Amanda didn’t suffer any long term effects from not experiencing the pain of her first labor, so how did feeling the pain of her second labor protect her?

Amanda had much more pain in the unmedicated parts of both labors compared to when she had a functioning epidural. So how did those endorphins provide relief?

Amanda was able to push her first child out despite having an epidural. So what exactly does she mean when she says she “responded” better the second time?

The bottom line is that Amanda’s pain with her second birth had NO purpose. It accomplished NOTHING. It changed NOTHING.

Well, that’s not completely true. It did have one purpose: it allows her to boast about her natural childbirth, and what could be a more important purpose than that?

Midwife Jessica Weed has helpfully provided yet another example in the seemingly endless parade of homebirth midwives who demonstrate emphatically that the CPM (certified professional midwife) credential is completely inadequate and should be abolished.

The stories share the same pattern over and over again:

1. High risk candidate taken on for homebirth? Check.

2. Serious injury (or death) for baby or mother or both? Check

3. Midwife tries to convince mother to lie about midwife’s presence? Check.

This time, however, the debacle ended with the arrest of the homebirth midwife, who is now facing felony charges.

According to Alberquerque TV station KRQE:

According to a criminal complaint, six days after Weed helped deliver a friend’s baby, the infant and mother were admitted into UNM Hospital.

Doctors say the baby had bleeding in the brain and retinas, and the mom still had not delivered the placenta which caused an infection.

The complaint says Weed asked the mother to write a letter and tell hospital officials she did not help with the delivery.

The mother finally told hospital workers the truth.

You can view the TV report here:

Midwife charged with child abuse

Even for a homebirth midwife, this represents an egregious case of negligence. The baby was so profoundly injured by the breech birth that he experienced bleeding his brain and his retinas, yet the midwife did not transfer him to the hospital. The mother retained the placenta within her uterus for DAYS (and, not surprisingly, developed an infection) yet the midwife did not transfer the patient to the hospital. The fact that Weed went so far as to insist that the mother write a letter insisting that she was not present at the delivery indicates that she understood her culpability and wanted to hide it.

Way to go, CPM!

The baby faces permanent brain damage, blindness and possibly death and the CPM is apparently more worried about her fate than that of an innocent newborn.
The mother faces a major infection, possible sepsis and possible loss of her uterus and the CPM is apparently more concerned about her fate than that of the mother.
It is unethical to lie about involvement in a medical case and it is unethical to pressure the mother to lie, but the CPM apparently places her own interests anything so mundane as ethical behavior.

And let’s not forget the other feature commonly associated with a horrific outcome at a CPM attended homebirth.

4. The local midwifery association supports the midwife, not the baby and not the mother.

According to the Alberquerque Journal:

An advocacy group for New Mexico midwives responded Monday by calling the arrest an unprecedented move that threatens to worsen a shortage of maternity care in the state…

The New Mexico Midwives Association issued a written statement Monday saying that licensed health care providers are regulated under civil law and that it is extremely rare for medical personnel to be criminally charged.

“If we used criminal law to hold health care providers responsible for their patients’ outcomes, our prison system would be overwhelmed,” Cassaundra Jah, a spokeswoman for the association, is quoted in the statement.

“If we are telling providers that they not only risk being sued, but arrested and put in jail for anything less than a perfect outcome, then we can expect to see an exodus of maternity and other health care professionals leaving our state,” Jah said.

I can’t comment on the appropriateness of filing felony charges of child abuse in this setting, but something must be done to hold this woman accountable.

Homebirth kills and hurts babies and mothers. Certified professional midwives (CPM) lack the education and training needed to prevent these disasters. The CPM credential must be abolished.

Benjamin Disraeli famously said, “There are three kinds of lies: lies, damned lies and statistics.”

Midwife Hannah Dahlen, in her ongoing efforts to blacken the reputation of obstetricians, corroborates Disraeli’s claim. Her latest paper, Rates of obstetric intervention among low-risk women giving birth in private and public hospitals in NSW: a population-based descriptive study, published in the current issue of the British Medical Journal Open edition has, is a master class in lying with statistics.

The primary conclusion of the paper is:

Over the past decade these interventions have increased by 5% for women in public hospitals and by over 10% for women in private hospitals. Among low-risk primiparous women giving
birth in private hospitals 15 per 100 women had a vaginal birth with no obstetric intervention compared to 35 per 100 women giving birth in a public hospital.

The part of the study that is generating media attention is:

TENS of thousands of Australian women with low risk of birth complications are undergoing unnecessary medical interventions in private hospitals in a trend that a leading midwifery expert has described as ”horrifying”.

Indeed, the authors of the paper state:

The continual rise in obstetric intervention for low-risk women in Australia is concerning in terms of morbidity for women and cost to the public purse. The fact that these procedures which were initially life-saving are now so commonplace and do not appear to be associated with improved perinatal death rates demands close review.

There is just one teensy, weensy problem with the paper:

The authors never looked at the perinatal death rate in the population that they studied so they literally have no idea of the impact of the interventions they decry. They performed a bait and switch; they looked at intervention rates in a low risk population and compared them to mortality rates in the overall population including high risk women, prematurity and all complications of pregnancy.

Let’s look at the population they studied, women from the Australian state of New South Wales:

The ‘standard primipara’ is defined as a primiparous woman aged 20–34 years, who had no pre-existing or pregnancy-related medical conditions, gave birth at 37–41 weeks gestation to a fetus in a cephalic presentation within the 10th and 90th centiles for birth weight. The ‘standard multipara’ was a multiparous woman aged 20–34 years, who had no pre-existing or pregnancy related medical conditions, gave birth at 37–41 weeks gestation of a fetus in a cephalic presentation within the 10th and 90th centiles for birth weight. In both definitions we included ‘non smoking’.

That yielded a study population of 124,431 women:

… 30 152 low-risk primiparous women who gave birth in a private hospital and the 94 279 low-risk primiparous women who gave birth in a public hospital.

But when it came time to compare the intervention rates to the mortality rate, the authors used the perinatal mortality rate from 691,738 births during the period 2000–2008. In other words, the perinatal death rate includes 567,307 women that aren’t in the study. In other words 82% of the mothers from whom the mortality rates are derived AREN’T in the study. Those are the women with high risk conditions, prematurity and pregnancy complications, and, of course, most of the perinatal deaths occur in that group.

Even then, the authors play fast and loose with the truth:

The NSW rate of perinatal mortality was between 8.6 and 9.6 per 1000 births between 2000 and 2005 and between 8.7 and 9 per 1000 births between 2005 and 2009.

That’s a rather curious way to describe a trend over time, but it sounds a lot better for Dahlen’s purposes than an accurate report of the information: from 2000-2008, overall perinatal mortality in New South Wales dropped from 9.7/1000 to 8.7/1000, a drop of 10%.

How did the reviewers let this bait and switch go by. BMJ Open provides the names and comments of the reviewers. The  reviewers for this paper are two midwifery professors Meredith McIntyre,  who researches “midwifery care reform” and Maralyn Foureur, a colleague of one of the authors on another publication, who researches “ways to keep birth normal.” In other words, to professional colleagues of the authors known to be in agreement with their views about interventions. There was no review by an obstetrician or a statistician.

One of the reviewers does note that in the original manuscript, the authors attempted to use perinatal mortality rates from Australia as a whole:

The national rate of perinatal mortality rather than the NSW state rate is used in the Discussion. It is more appropriate to use the NSW rate in order to better support your argument that the increase in interventions for private women does not result in improved benefits for babies…

She’s only half right. It is indeed inappropriate to use the national perinatal mortality rate, but it is also inappropriate to use the NSW rate of perinatal mortality. The correct comparison would require the use of the perinatal mortality rates in the group of low risk women under study.

The BMJ ought to re-evaluate the way that it reviews papers. Professional colleagues allies of the authors should not be used as reviewers, claims about obstetric interventions should be reviewed by obstetricians, and statistics claims should be reviewed by statisticians.

The bottom line is that this study tells us only the trend of intervention use among low risk women in NSW from 2000-2008 and the difference in intervention rates between low risk women in private and public hospitals. That’s all it can tell us. There is no information presented that would allow us to draw conclusions about whether the interventions were used appropriately or whether they led to a decrease in perinatal mortality.

In contrast to Ms. Dahlen’s claims, what is “horrifying” here is not the increase in interventions, but the bait and switch used  in the attempt to advance the midwifery objective of blackening the reputation of modern obstetrics.

Today’s post on Science and Sensibility is an object lesson in everything that is wrong with contemporary natural childbirth advocacy.

The post is entitled The Importance of Understanding and Reversing Disparities in Maternal Health Outcomes, and it proports to be a good faith examination of the high maternal mortality rate among women of color in the US.

How does it illustrate what is wrong with contemporary natural childbirth advocacy? Let me count the ways.

1. It is a cynical exploitation of the issue of maternal mortality.

Following the lead of NCB Cynicist-in-Chief Ina May Gaskin, it raises the issue, not out of genuine concern for women of color, but merely to portray modern obstetrics as a system “in crisis.” Ina May Shows how its done:

Cynically ignore the real crisis in the care of women around the world who die for lack of access to modern obstetric care, and pretend that the “crisis” is that there aren’t more midwives to care for well white women in first world countries. Cynically ignore the fact that the leading causes of maternal mortality in the US are complications of pregnancy and pre-existing medical conditions like heart disease and kidney disease. Midwives can have no impact on these deaths because they don’t care for these patients.

Ina May represents herself as shocked at the current rate of maternal mortality, going so far as to create (and publicize) a memorial quilt. Yet as far as far as I can tell, Gaskin has done NOTHING (no research, no education, no fund raising) to reduce the incidence of maternal mortality. In contrast, modern obstetrics has lowered the maternal mortality rate 99% PERCENT in the past century.

2. Lying by omission is a favorite tactic of NCB advocates. Even so, the disingenuousness of these piece is astounding. Watch how it works in practice.

Write:

The CDC paper compares women of different races, ethnicities and nativity (US or foreign-born) from 1993-2006. They found that for all women, “the pregnancy-related mortality ratio (PRMR) increased significantly (P

But don’t mention:

In 1999 and again in 2003, the US Standard Certificate of Death was revised to ask explicitly whether any female death was associated with pregnancy, instead of relying on the person filling out the form to voluntarily provide that information and the definition of maternal death was expanded.

The results of these changes are captured by the following graph.

Write:

African American women have a three to four-fold greater chance of dying as a result of pregnancy than women in any other racial-ethnic group.

But don’t mention:

The disparity between women of African descent and women of other races occurs in all first world countries, among all practitioners including midwives.

Write:

… [E]xperts today commonly state that reasons for this disparity are “not fully understood,” and “limited data exist” to explain why they continue to occur.

But don’t mention:

The lack of understanding is not from lack of trying to understand. This is one of the most intensive areas of public health and obstetric research.

3. Play the one note samba.

Like a piece of music with only one note, natural childbirth advocates have only one response to every situation: question the use of “interventions.”

At this point, it’s like a Monty Python sketch:

Man: “My wife died in childbirth.”
NCB Advocate: “Did she have an episiotomy”

Man: “She died of cardiac complications?”
NCB Advocate: “How unfortunate. Did she have an episiotomy?”

Man: “She had a history of congenital heart disease that led ultimately to her death.”
NCB Advocate: “Bummer. Did she have an episiotomy?”

The authors of the Science and Sensibility piece does not bother to mention that the contemporary causes of maternal mortality are changing. At this point, maternal cardiac disease is one of the leading causes of maternal death. Cardiac disease includes peripartum cardiomyopathy, and underlying cardiac conditions, particularly congenital cardiac anomalies. These women die because of lack of access to advanced medical technology, not because of medical technology.

Yet NCB advocates are still banging away on the same note:

… [P]ublic health paradigms have more often focused on antecedents to care (access to contraception and prenatal care) and outcomes (mostly newborn and infant health) with less attention to the processes of care or interventions during the birth itself.

Those interventions being:

… five major interventions used in the birth process: induction, electronic fetal monitoring, epidurals, episiotomy, and cesarean section.

Is there any scientific evidence that these interventions have any impact on maternal mortality? The author references a book chapter Contemporary Childbirth in the United States: Interventions and Disparities. I just read that chapter. In 43 dense pages of texts and charts, its authors provide NO evidence that the use of interventions in childbirth is related to maternal mortality in any way.  No evidence, none, zip, zero, nada.

No problem. That was never the point of the post. The point of the post was to suggest a maternity system “in crisis,” to deliberately misrepresent the problem, and to provide yet another opportunity to bang away at the one note samba. Mission accomplished!

When faced with a high rate of maternal mortality among African Americans, the question that NCB advocates want to know is: did she have an episiotomy? If asking that question in the face of horrible tragedy is not cynical, I don’t know what is.

No mother should ever die at homebirth.

Maternal deaths in the hospital are unusual; perinatal deaths are 100 times more common. There are so few maternal deaths in the developed world that they are measured per 100,000 and most of the women who die have serious medical complications like cardiac disease or pre-existing medical conditions. Death from a routine childbirth complication like bleeding is almost unheard of in an age of blood transfusions and surgical repair.

That’s why it’s horrifying to consider the latest report of a maternal death at homebirth. This marks the 4th publicly reported maternal death at homebirth in the past 4 years. All 4 women were in excellent health prior to childbirth and at least 3 (possibly 4) out of 4 simply bled to death.

Joanne Whale bled to death in 2008 as a result of a uterine eversion. Her midwife did not even know how to start an IV.

Sara Hedgepeth Osceola, mother of 6 small children, bled to death while attempting a VBAC at home.

Caroline Lovell, a homebirth activist, died shortly after she gave birth to her daughter.

Now comes word that Claire Teague bled to death due to retained placenta while the midwife went home.

According to the Mail Online:

A mother died within hours of giving birth at home after a private midwife committed a horrifying catalogue of errors, an inquest heard.

Claire Teague, 29, was left bleeding in bed after Rosie Kacary allegedly pulled out her placenta following the delivery.

The midwife is also accused of failing to realise a large section of the placenta had not come out and not stitching a tear.

In addition:

Mrs Teague complained to her husband, Simon, about feeling weak and in pain after the birth but Kacary left and only returned after ‘repeated contact’.

When she came back to the couple’s home in Woodley, near Reading, Berkshire, she discovered Mrs Teague had stopped breathing.

Instead of performing CPR on a firm area such as the floor, Kacary is said to have done it on the bed, where it was less effective…

The midwife left at 10am. Mr Teague claimed that when she eventually returned and attempted to resuscitate his wife, she ‘didn’t seem to know what she was doing’.

The inquest heard from a paramedic who described the ambulance that took Mrs Teague to the Royal Berkshire Hospital as ‘swimming in blood’.

Doctors established around a third of the placenta – measuring 8in by 3in – had not been delivered.

Kacary believes that she did nothing wrong and (the classic excuse of the homebirth midwife)  the patient would not have accepted advice to transfer.

She believed the placenta had been complete and said, if she thought otherwise, she would have advised an immediate hospital transfer.

But she said: “As Claire felt completely well at the time, I’m very sure they would have declined my suggestion to transfer.”

Why did Claire Teague die?

A post mortem found that Mrs Teague died due to a lack of oxygen caused by the severe haemorrhage due to a recent vaginal birth with a retained placenta.

But, according to Kacary, at least she had a great birth!

“Claire had a great pregnancy, she had a really lovely spontaneous birth at home and I hope Simon in time will remember that.”

Because when it is all said and done, for a homebirth midwife, it’s all about the process, and death is a small price to pay for a great birth experience.

If you want to understand the gulf that separates natural childbirth advocates from obstetricians, check out the latest midwifery and obstetric journals. No, none of this month’s issues have a paper about the difference. Rather, it is the type of papers in each that illustrate the difference.

Let’s start with the natural childbirth journal Birth, published by Lamaze International. There are 13 articles and reviews in the September issue: 8 are about the patient experience of childbirth, 3 are concerned with the provider experience and beliefs, only 1 is focused on safety outcomes for babies or mothers, and none contribute original knowledge.

Contrast that with the September issue of Obstetrics and Gynecology. There are 15 obstetrics articles: of these, 1 is about the patient experience, 1 is potentially concerned with provider experience and beliefs, 10 are focused on safety outcomes for babies and mothers, and 8 contribute original knowledge (each article can be counted in more than one category).

In other words, the vast majority of articles in Birth focuses on patient or provider experience, only 1 paper focused on actual outcomes for mother and or baby and there was no research that contributed to the body of scientific evidence about obstetric practice. In Obstetrics and Gynecology, the proportions were reversed. The majority of articles focused on safety outcomes for mothers and or babies and more than half contribute original knowledge to the body of scientific evidence about obstetric practice. Only 1 article focuses on patient experience, and one potentially focuses on provider experience.

These findings extend to other midwifery and obstetric journals. Below is a table with the results of an informal analysis of the latest issues of the 3 most prominent midwifery journals and the 3 most prominent obstetric journals. (In addition to Birth and Obstetrics & Gynecology, they include Midwifery, the British Journal of Midwifery, the American Journal of Obstetrics and Gynecology, and the British Journal of Obstetrics and Gynecology.

Of note, the proportions do not add up to 100% because an article can be counted in more than one category (eg. safety outcomes and original knowledge).

A bar graph of the same data expresses the difference even more dramatically.

What is striking to me is how little midwifery research is concerned with safe outcomes. All of the midwifery journals devote a proportion of 20% or smaller to safe outcomes. Presumably that is not because midwives and natural childbirth advocates don’t care about childbirth culminating in a healthy mother and healthy baby. I suspect that the reason for the bizarre lack of interest in safe outcomes is two fold. First, midwives and natural childbirth advocates see no reason to even think about women who are high risk. If they are outside the scope of practice, these women are simply ignored. Second, midwives and natural childbirth advocates appear to assume that low risk women will nearly always have safe outcomes. That, of course, is a serious problem, since childbirth is inherently dangerous, even for women who are low risk. Midwives and natural childbirth advocates can pretend that the dangers don’t exist because they have been virtually eliminated by the interventions of modern obstetrics, the very interventions that they deplore.

Simply put, the real difference between natural childbirth advocates and obstetricians is that natural childbirth advocates live in a fantasy world of their own construction. In that fantasy world, childbirth is always safe, so there is no reason to ever worry about safety. Hence midwifery journals are filled with articles obsessing about whether women had IVs or midwives enjoyed themselves at their patients’ births. Obstetricians, in contrast, live in the real world, where low risk women can and do routinely have life threatening complications. Their priority is safe childbirth: healthy babies and healthy mothers.

There has always been something Orwellian about natural childbirth, from it inception in a monstrous racist lie (primitive women don’t have pain in childbirth) to its insistence on euphemism (rushes = contractions, vocalizing = screaming). Natural childbirth employs a form of “Newspeak,” author George Orwell’s term for language designed to prevent the thinking of prohibited thoughts. According to Wikipedia:

… Newspeak is closely based on English but has a greatly reduced and simplified vocabulary and grammar. The totalitarian aim of the Party is to prevent any alternative thinking — “thoughtcrime”, or “crimethink” in the newest edition of Newspeak – by destroying any vocabulary that expresses such concepts as freedom, free enquiry, individualism, resistance to the authority of the state and so on…

Moreover:

The aim of Newspeak is to remove all shades of meaning from language, leaving simple concepts (pleasure and pain, happiness and sadness, goodthink and crimethink) that reinforce the total dominance of the State. Newspeak root words serve as both nouns and verbs, further reducing the total number of words; for example, “think” is both noun and verb, so the word thought is not required and can be abolished…

Hence “gave birth” becomes “birthed.”

Natural childbirth advocates love mantras. They are a Newspeak way of claiming something without ever having to prove it. One of the most favored, and over used mantras is that obstetricians don’t practice evidence based medicine. Indeed, when natural childbirth advocates invoke the phrase “evidence based,” it is almost always a short hand way to criticize modern obstetrics. I was interested, therefore, to check out a new natural childbirth website called Evidence Based Birth. I wasn’t disappointed; it is profoundly Orwellian in many ways, particularly in its use of Newspeak and its shocking lack of scientific evidence.

I have already criticized the author, Rebecca Dekker, for her deliberately misleading guest post for Science and Sensibility in which she poses one question and deliberately and misleadingly answers another.

Now let’s look at the latest post on her own blog. Entitled Labor Day 2012: The State of Evidence-Based Maternity Care in the United States, it is remarkable for the fact that it doesn’t contain even a single piece of evidence, not one, to support its central claim that obstetrics in 2012 is not based on scientific evidence. Even Orwell would be impressed by that.

Who is the author of the website and what are her qualifications for writing about scientific evidence in modern obstetrics? Once again Orwell would be proud. Rebecca L. Dekker, PhD, RN, APRN, is an assistant professor of nursing at the University of Kentucky:

… holds a Master of Science in Nursing and Doctor of Philosophy in Nursing from the University of Kentucky. Her research focuses on improving the health outcomes of patients with heart failure who are experiencing symptoms of depression. She has served as the primary investigator on six studies examining the link between depression and heart failure outcomes. She recently completed a randomized, controlled study testing a brief cognitive therapy intervention for depressive symptoms in hospitalized patients with heart failure…

In other words, she has precisely zero training and experience in modern obstetrics, midwifery or even obstetric nursing. Like most self-proclaimed “birth professionals,” birth is her hobby. Perhaps that explains why she can’t find even a single piece of evidence to back her central claim.

As I have written in the past about the extraordinary claim that modern obstetrics is not based on scientific evidence:

We are supposed to believe that obstetricians (with 8 years of higher education, extensive study of science and statistics, and four additional years of hands on experience caring for pregnant women), the people who actually DO the research that represents the corpus of scientific evidence, are ignoring their own findings while NCB advocates (generally high school graduates with no background in college science or statistics, let alone advanced study of these subjects, and limited experience of caring for pregnant women), the people who NEVER do scientific research, are assiduously scouring the scientific literature, reading the main obstetric journals each month, and changing their practice based on the latest scientific evidence.

Extraordinary claims require extraordinary evidence. To my mind, that should include, at a minimum, 10 solid examples of current obstetric recommendations, central to the practice of obstetrics, that ignore current scientific evidence.

Let see what Dekker offers in her post.

1. A definition of evidence based medicine: so far so good.

2. Praise for the Cochrane Reviews: Dekker immediately goes right off the rails. She apparently doesn’t realize that the Cochrane Childbirth Reviews are riddled with statistical errors. She apparently doesn’t realize that the Cochrane reviews are all systematic reviews, a form of scientific evidence particularly subject to bias

• There are numerous ways in which bias can be introduced in reviews and meta-analyses of controlled clinical trials.
• If the methodological quality of trials is inadequate then the findings of reviews of this material may also be compromised.
• Publication bias can distort findings because trials with statistically significant results are more likely to get published, and more likely to be published without delay, than trials without significant results…
• Criteria for inclusion of studies into a review may be influenced by knowledge of the results of the set of potential studies…

These limitations can be summarized by the pithy phrase “garbage in, garbage out.” A meta-analysis or systematic review is only as good as the quality of the papers reviewed.

3. How does contemporary obstetric care compare to evidence based care? Answering that question would involve presenting the actual scientific evidence for various obstetric practices. Dekker doesn’t bother. Instead she provides a bunch of irrelevant crap and expects her gullible readers to be impressed.

• She is sure that there are too many C-sections but provides no evidence of an optimal number.
• She is sure that there are not enough VBACs but references a government goal, not the scientific evidence.
• She is sure that there are too many inductions, but she provides no evidence of an optimal number and throws in the irrelevant claim that Cytotec is being used off label.

Most of the remainder of her examples concern atmospherics that are the subject of hospital policy, not obstetric practice. Where is the discussion of the major issues of contemporary practice? Where is the discussion of preventing hypoxic ischemic encephalophathy? Missing. Where is the discussion of preventing preterm birth? Missing. Where is the discussion of management of postdates? Missing. Where is the discussion of treating obstetric complications like hemorrhage? Missing. Instead we have the substitution of NCB tropes like whether or not women should get out of bed during labor.

4. Having provided no evidence for any of her assertions, having ignored most of the major issues in contemporary obstetrics, and having proved nothing, Dekker concludes in a flourish of Newspeak:

… the vast majority of U.S. women are not receiving evidence-based care during childbirth.

We may not be able to draw a conclusion about modern obstetric practice from Dekker’s drivel, but we can draw a conclusion about her website. The website Evidence Based Birth, yet another natural childbirth website put together by a hobbyist with precisely zero experience in obstetrics or midwifery, is just a collection of typical NCB Newspeak. It has nothing to do with evidence, and everything to do with the classic aim of Newspeak: to enforce ideological conformity, the truth be damned.

Earlier this year I criticized a paper that claimed that the Birthplace study showed that homebirth is cost effective.

… the study CAN’T tell us about cost effectiveness since it does not take into account the largest costs, the costs of caring for a child injured during birth and the massive costs associated with legal settlements for babies who were injured or died.

There is another issue that I did not address in that post: even leaving aside long term costs of injuries and brain damage, homebirth can never be cost effective. To understand why, it helps to consider a simple example, such as making a pair of pants.

Which pair of pants costs more:

1. The pair of pants fabricated by Joe, using machinery costing tens of thousands of dollars?

2. The pair of pants sewn by Jane using her $800 sewing machine?

At first glance, it seems that the pair of pants created with the inexpensive machine surely costs less to produce, and that would be the case if Joe used his machinery to produce only a single pair of pants. However, Joe uses his machinery to produce 1,000 pairs of pants a day, 5 days a week, 50 weeks a year. Not only that, Joe obtains his fabric on industrial sized bolts at wholesale prices, while Jane has to pay retail price for a small quantity at her local fabric store. Similarly, Joe buys other supplies, like thread, needles and zippers in bulk, leading to lower prices per unit of each item than what Jane must pay.

When the cost of the expensive initial investment is spread over the hundreds of thousands of pairs of pants that Joe produces each year, the actual cost of a pair produced by Joe is far, far less than the cost of a pair produced by Jane. This principle is known as “economies of scale.” As Wikipedia explains:

… There are factors that cause a producer’s average cost per unit to fall as the scale of output is increased. “Economies of scale” is a long run concept and refers to reductions in unit cost as the size of a facility and the usage levels of other inputs increase.

… The common sources of economies of scale are purchasing (bulk buying of materials through long-term contracts), managerial (increasing the specialization of managers), financial (obtaining lower-interest charges when borrowing from banks and having access to a greater range of financial instruments), marketing (spreading the cost of advertising over a greater range of output in media markets), and technological (taking advantage of returns to scale in the production function). Each of these factors reduces the long run average costs (LRAC) of production …

The same economic rules apply to providing obstetric care. At first glance, it appears to cost less for Jane to have a homebirth, than for Joanna to give birth in the hospital. However, when governments are considering the cost of obstetric care, they aren’t looking at individual cases; they’re looking at providing obstetric care for an entire population. It is far more cost effective to provide obstetric care at a centralized facility where a variety of providers can care for many patients at the same time than it is to provide care in a private home where each midwife can care for only one patient at a time.

Many countries, like the UK, have moved to centralize care in regional hospital facilities instead of multiple community hospitals. In a regional facility, 10 midwives can care for 60 patients or more at the same time, since they are in different stages of labor and will not all deliver at the same time. In contrast, 10 homebirth midwives can care for 10 patients in the same amount of time. So while the cost of an individual homebirth attended by a midwife might appear smaller, long run average costs are much, much higher.

Homebirth advocates are looking at the wrong metric, the cost of an individual birth, when declaring that homebirth costs less than hospital birth. The correct metric is the cost of providing obstetric care to the entire population in a given time period. By that measure homebirth is woefully cost ineffective. In countries like the UK, where there is a shortage of midwives, homebirth is probably the least cost effective option of all.

Imagine if someone wrote an article entitled, What is the Evidence for Treating Chest Pain in Healthy Men? and claimed:

There is no evidence that hospitalization for chest pain in men improves outcome.

Makes it sound like there is no reason for a man to worry if he has chest pain, no reason to call 911, no reason to take an aspirin, no reason to do anything, doesn’t it?

That’s what most people would take away from the article, even if they read the caveat.

There is no evidence that hospitalization for isolated chest pain in otherwise healthy men has any beneficial impact. Based on the lack of evidence, any recommendation for hospitalization for chest pain with no other symptoms, no underlying risk factors, no complicating conditions, and normal test results is a weak recommendation based on clinical opinion alone.

Okay, now it’s clear. The article is actually talking specifically about chest pain that has already been determined to be unrelated to any cardiac issues. Well, duh! No one ever claimed that every episode of chest pain was a heart attack, but that doesn’t mean that chest pain should be ignored.

In other words, the article itself would be considered deeply misleading, suggesting as it does that there is no reason to pay attention to chest pain.

Rebecca L. Dekker, PhD, RN, APRN has written an equivalently misleading article for Science and Sensibility, entitled What is the Evidence for Induction for Low Amniotic Fluid in a Healthy Pregnancy?

She claims to be answering the following question:

Low fluid seems to be the new “big baby” for pushing for induction. What does the research say about low fluid at or near term? From what I’ve been able to see in research summaries at least, there appears to be no improved outcome for babies, but I’d love to see the research really hashed out…

Decker writes:

There is no evidence that inducing labor for isolated oligohydramnios at term has any beneficial impact on mother or infant outcomes.

But that’s not what the questioner asked. She asked about oligohydramnios, not about isolated oligohydramnios. Decker does not even bother to answer the actual question since that would require acknowledging that there is plenty of scientific evidence that oligohydramnios can lead to perinatal death and poor outcomes. Instead, she decides to address a subset of cases of oligohydramnios while never making it clear that this is what she is doing.

There’s a big difference between oligohydramnios and isolated oligohydramnios. In this context, isolated means oligohydramnios in women who have NO other abnormalities, NO underlying risk factors, NO complicating conditions AND normal test results. No one ever claimed that every case of oligohydramnios is a sign of impending disaster, but that doesn’t mean that oligohydramnios should be ignored. To the contrary, it should be investigated vigorously.

As Zhang et al. point out in an paper on isolated oligohydramnios:

It is well established that oligohydramnios is associated with a high risk of adverse perinatal outcomes. On the other hand, oligohydramnios is a poor predictor for adverse outcomes.11,12 An explanation for these seemingly conflicting observations lies in the fact that not all oligohydramnios are the same. Our study shows that oligohydramnios with unfavourable maternal and/or fetal conditions (such as IUGR, anomalies or hypertension) leads to a much worse perinatal outcome than a normal amniotic fluid volume with the same conditions. In these cases, oligohydramnios may be an indicator of a more severe impaired placental function, fetal compromise and worse maternal/fetal conditions. However, we found in the current study that about half of the oligohydramnios cases did not have any coexisting medical or obstetric conditions. Fetuses in these cases tend to be appropriately sized at the diagnosis of isolated oligohydramnios. More importantly, with advancing gestation, their growth does not seem to be impaired… (my emphasis)

Dekker employs the classic NCB technique for deliberately misleading women: the bait and switch. She poses one question (what does research say about oligohydramnios), but answers another, different question (what does research say about isolated oligohydramnios, a subset of all cases of oligohydramnios).

Oligohydramnios is a symptom. As such, it requires investigation to determine whether there are other abnormalities such as fetal growth restriction, maternal hypertension, etc. If any additional symptoms or complicating conditions are found, induction is often the appropriate treatment to reduce the risk of perinatal death. Only IF the search for other symptoms and complicating conditions has revealed NOTHING ELSE can we conclude that there is no need for induction.

Dekker should be ashamed of herself for writing such a deliberately misleading article and Science and Sensibility should be embarrassed to publish it. But I suspect neither will be moved, since it appears that deliberately misleading women is a central element of natural childbirth advocacy. When there is no scientific evidence to support your position, the only way to convince women is the bait and switch.