#1 Sterling:

It felt like an eternity, but finally I was crowning… The head eventually was completely out, and there was a shift in everyone’s tone… They frantically moved me from position to position trying to get the baby free. The cord was wrapped around the neck, and his shoulders were stuck. They moved me to my back once more and Lisa got a good grip and pulled the baby from within me. I felt the baby slide out and I saw him lying there on the floor. it was 11 am May 28. He was blue. He was so beautiful. He was a boy…He was not breathing…

I won’t go into the details of our time in the hospital … But I’ll give a quick overview… Sterling was on the ECMO for 1 week, which essentially is a mechanical lung and heart. The doctors and nurses pumped oxygenated blood from the machine, into our baby’s heart through a tube in his jugular vein. The blood circulated through his body and back out into the machine. This allowed his lungs to heal from the infection. his heart had a chamber that collapsed and this treatment allowed his to recover from that. He was in a drug induced stupor for most of his stay. They kept him on a ventilator for a week, then switched it to a less traumatic ventilator. Then eventually to an oxygen tube. He was in the NICU for 1 and a half weeks, and in a recovery room for 5 days.. A total of 3 1/2 weeks in the hospital. He made tremendous leaps there in terms of healing and was a completely normal healthy baby boy when we brought him home. No brain damage no nothing. Except for a few small scars 🙂

Was it because of homebirth? No, that was just an incredible coincidence!

… [T]ake note that the trauma we experienced had nothing to do with our son being born at home. We still support home birth!

#2 Tina’s son:

… I wasn’t ready for homebirth with our daughter, which, unfortunately turned into an experience that was everything I didn’t want (many factors as to why this happened)…so for our next birth, we did all the research and preparation to have the kind of birth we wanted, at home. Sadly, this birth ended with our son being born dead. No amount of resuscitation worked…by the midwives or the paramedics that arrived within a few short minutes (and quickly whisked him away to the hospital)… nothing worked. He just couldn’t be resuscitated.

Was it because of homebirth? No, that was just an incredible coincidence!

I do not blame this on being home…we don’t know why he died. And regardless, death can happen at birth no matter where the baby is born. We were one of the unlucky to have this happen to us, at home. It could have also happened had we been at the hospital…we just don’t know what happened…Anyway I am still a strong supporter of homebirth and I know many many people who’ve had happy homebirth stories. Ours was our midwife’s first tragedy. In over 30yrs of hundreds and hundreds of homebirths, she’s only had this one death. Unfortunately it was us. But I don’t want anyone to be scared by our story…because every other story I know had a happy outcome…and I know A LOT of stories!

#3 Charlie’s story (webcache)

This page is for my daughter, Charlie. She suffered an HIE event in utero which damaged her brain significantly. She has cerebral palsy, seizures, a feeding tube, and many other medical issues…

And:

… YOU were not there, so you cannot comment on what “really” happened. You don’t know! I’ve not lied, or exaggerated the details of her birth. She really was born with a heart rate of 130-140. My midwife really did use the doppler quite frequently in the last stages of the birth. We have the whole thing ON TAPE. We are not deluded into thinking that all was well when it really wasn’t. Charlie TRULY did not give us any signs of distress.

Was it because of homebirth? No, that was just an incredible coincidence!

Shit happens. Shit happens EVERYWHERE. Shit happened to my friend who is a doctor in the hospital she gave birth in…

Bottom line, if a woman loses a baby at home, she is no more at fault than the woman who loses a baby at the hospital.

Three homebirth disasters: a severely injured baby, a permanently brain injured baby and a dead baby. But, really, it had nothing to do with homebirth. It had nothing to do with the fact that each of these babies needed an expert neonatal resuscitation with intubation and homebirth midwives don’t know how to intubate. Absolutely not!! And babies die in the hospital, too!

It’s it all just an amazing coincidence.

Barbara Herrera (Navelgazing Midwife) has some advice for homebirth advocates. Apparently she is disgusted with Jennifer Block’s attempt to divert attention from the facts in Michelle Goldberg’s piece, Home Birth: Increasingly Popular But Dangerous.

She notes that difference between Goldberg’s original piece and Block’s obsession with me:

Out of 39 paragraphs, Dr. Amy Tuteur (the Skeptical OB) is quoted in four and mentioned in a fifth, yet the afterquakes have, almost exclusively, have centered around including Tuteur as a source for Goldberg’s article.

In fact, in The Slate, Jennifer Block’s piece entitled, “How to Scare Women: Did a Daily Beast story on the dangers of home birth rely too heavily on the views of one activist?” contains 16 paragraphs and Tuteur is highlighted in ten of those, not including the obvious reference to her in the title…

So, why am I up at 2am counting paragraphs in tit-for-tat articles? First, because I cannot believe the energy spent on Dr. Amy… so many people arguing for or against her as a source. It’d be amusing if it weren’t such a serious topic. It’s really important for people to know that Dr. Amy isn’t going anywhere and that she will continue to be used as a source protesting Certified Professional Midwives and much of home birth. I know women who begin reading an article or post and if Tuteur is mentioned, abruptly end their reading session. Dr. Amy has been a source in over a dozen articles, from the Los Angeles Times, the New York Times and Time.com; it’s unlikely she’s going anywhere.

As NGM points out, whining about me is not simply a losing battle; it is a losing strategy in any effort to defend the poor safety record of homebirth midwives:

As much as Dr. Amy Tuteur makes some people crazy, she has proven she is not a force to ignore. While I have issues with her delivery and am unsure about all she professes as fact, the woman has things to say that need to be heard and she’s going to be heard, whether we like it or not. Instead of trying to make her go away, how about we find people who can argue with/speak out against what she says in the same articles. And for crying in a bucket, debating statistics is not the way to do it! If you haven’t figured it out yet, the stats’ results are in the eye of the beholder, so finding alternative discussions is crucial. One of my favorite topics is why women want an out-of-hospital birth in the first place. And then it needs to move quickly to choosing safe home birth midwives. I believe until we have clear, fantastic midwifery education and a way for them/us to learn the advanced skills necessary for out-of-hospital births, we’re fighting a losing battle. Dr. Amy has the information about CPMs down to a sound bite; we better have an answer about them/us when asked.

I have an even better idea:

Instead of attempting to counter my recitation of the abysmal homebirth death rates, how about actually addressing the issue.

As one of the commentors on NGM’s piece notes:

I am profoundly uncomfortable with all the Amy-bashing that goes on. Granted, the woman is strident, vocal, and opinionated, but what the heck?, since when are we all supposed to be shrinking violets? I suspect that she makes people profoundly uncomfortable because she zeroes in on all the stress points in midwifery care like a homing missile. Uneven/inadequate training? Check! Lack of accountability? Check! Absence of informed consent, good backup, timely transport? Check, check, check! She pushes people to address issues they’d rather gloss over. And THAT in my opinion is why she is so reviled.

Jennifer Block has made a fool of herself attempting to divert attention from the appallingly high death rates at the hands of homebirth midwives. Her grade school tactics of attacking the messenger instead of a addressing the message merely aids me in my on going attempt to abolish the CPM (certified professional midwife) credential. CPMs are grossly undereducated, grossly undertrained hobbyists who have appalling rates of neonatal death, and to the extent that they address those unacceptable death rates, it is only to find new (and particularly ineffective) ways to hide them.

Jennifer Block is the “whack-a-mole” of childbirth journalism. She periodically pops up in mainstream publications to defend homebirth with a stream of mistruths, half truths, and outright lies. Then, when it is pointed out that she has been deliberately misleading, and sometimes altogether dishonest, she disappears, only to pop up several months later to issue the same falsehoods and disappear again.

For example, in her unprofessional attempt to divert everyone’s attention from the statistics that Michelle Goldberg published in her piece in The Daily Beast, Block doesn’t bother to rebut the data, indulges in ad hominems (most of which are lies, but that’s another story) and quotes two professionals without mentioning that both are prominent in the American homebirth movement (Doesn’t Slate employ editors and fact checkers? Apparently not for this piece.)

Melissa Cheyney is described as an anthropology professor without disclosing that is the Director of Research for the Midwives Alliance of North America (the leading organization of American homebirth midwives); and Gene Declercq whom Block describes as “an epidemiologist,” but whose bio states:

Gene Declercq combines formal training in political science with almost twenty years of experience as a certified childbirth educator to examine policy and practice related to childbirth in the US and abroad… He was a technical advisor to the film documentary, The Business of Being Born…

Now that Michelle Golberg has exposed Block’s “bad faith approach” in a follow up article in The Daily Beast, and I have challenged Block to a public debate, she has made herself scarce. It’s hardly the first time. So once again I challenge her to a public debate, and maybe this time she’ll have the intellectual integrity to participate.

The following is the challenge that I issued to Block in August 2009:

Homebirth advocate Jennifer Block must be grateful to RH Reality Check for getting her off the hook. They deleted the data that I posted so she did not have to address it. Block has decided to respond publicly, this time on Babble.com Who’s winning the homebirth debate?

Well, she didn’t actually respond. How could she? The data is quite clear on the point that homebirth increases the risk of neonatal death. So she did what homebirth advocates love to do, she tried to think up reasons why no one should bother to address the scientific facts:

…So omnipresent has Dr. Amy been on the boards that she began to take on a mythical status among the home birth community. Some activists believed she wasn’t real, that her picture and bio were fake, that she was a mere avatar for some sort of underground ACOG propaganda machine …

But “Dr. Amy” is real. I sat with her, face to face, for nearly three hours at a Starbucks off Route 1 south of Boston a couple years ago. She is not a researcher, not an epidemiologist, and probably not on anyone’s payroll; she is an obstetrician-gynecologist who left private practice more than a decade ago because, she told me, she’d had it with HMOs and wanted to spend more time with her four kids (she let her license lapse in 2003, according to the Massachusetts Board of Medicine). And for some reason, which I never quite got to the bottom of, she believes in every cell that Home Birth Kills Babies (that’s in fact the title of her most recent post on her new site, The Skeptical OB), and no amount of research evidence will convince her otherwise.

Interestingly, Ms. Block, in yet another 3 page screed, doesn’t bother to present any actual evidence. That’s not surprising. There is none.

Here’s my response:

Dear Ms. Block,

Let’s make it very easy for women to compare and contrast the claims:

I challenge you to a public debate on the safety of homebirth in any neutral forum of your choosing, whether print, other media or a public appearance.

We can address these specific points:

1. All the existing scientific evidence (including the Johnson and Daviss BMJ 2005 study) shows that homebirth with a direct entry midwife has nearly triple the rate of neonatal death for comparable risk women in the hospital.

2. American direct entry midwives do not meet the standards for licensing in ANY first world country. They do not meet the standards in the Netherlands, the UK, Canada, Australia, anywhere.

3. The Midwives Alliance of North America, the group that collected the statistics for the BMJ 2205 study) has continue to collect safety statistic from 2001-2008. They are currently hiding those statistics from the public. They should be required to release those statistics so women can decide for themselves if CPMs are safe practitioners.

4. According to the World Health Organization, the US has one of the lowest levels of perinatal mortality in the world, lower than Denmark, the UK and the Netherlands.

I welcome publicly debating you or any other homebirth advocate in any neutral setting. I’m not holding my breath though; neither you nor any other homebirth advocate will agree to a public debate because you know my data is correct and my case is airtight. No one in the world of homebirth advocacy can risk the embarrassment.

How about it, Ms. Block? If you are so sure about what the scientific evidence shows, you should welcome an opportunity to discuss it point by point. Perhaps the folks at Babble.com Slate might be interested in hosting the debate.

After all, don’t women deserve the opportunity to analyze both your claims and my claims and reach their own conclusion about what the scientific evidence shows?

P.S. I’m not holding my breath. If past is prologue, Block wouldn’t dare participate in a public debate. It’s time once again for the mole of childbirth journalism to disappear before she gets whacked.

Addendum: Jennifer Block has proved my point for me.

Instead of responding to Michelle Goldberg’s evisceration of her “bad faith approach” and instead of agreeing to a public debate with me of the scientific data and state, national and international statistics, she has popped up on her own blog … and disabled the comments so she can’t even be questioned or corrected!

Jennifer Block knows she cannot defend her mistruths, half truths and outright lies in any forum where she could be questioned. So like the mole in whack a mole, she drops out of sight and pops up again in a place where no one can challenge her. It’s a tacit admission that she cannot defend her claims.

Jennifer Block made a big mistake this time. No, I don’t mean her habit of offering mistruths, half truths and outright lies, nor her propensity to ignore facts that she doesn’t like, not even her pathetic substitution of ad hominem attacks against me in place of addressing the data that I presented. In her recent Slate piece, she questioned the integrity of another journalist, Michelle Goldberg, and it has blown up in her face.

Block didn’t know about Goldberg what I learned about her. She is the most thorough, in depth reporter I have ever dealt with. She immersed herself in the topic over a period of weeks, interviewed dozens of people and followed up on everything. When I told her about the Johnson and Daviss paper and the bait and switch they perpetrated to make homebirth look safe when their data showed it wasn’t, she called them and offered an opportuntity to explain. Apparently, they weren’t able to explain away the bait and switch.

When I told her about women who lost babies at homebirth, she spoke to nearly a dozen of them. She talked to other obstetricians, a pediatric emergency room chief, and many more people who are directly and indirectly affected by the homebirth issue. The article that she eventually produced only hinted at the tremendous amount of research that went into it, as well as the strenuous efforts to follow through on every claim, and the opportunities given to homebirth advocates to explain their previous actions.

Goldberg draws on this research in a published response to Block’s accusations:

… I’m grateful for Block’s piece, since it gives me a chance to wade into some of the disputes that I elided, for reasons for space and readability, in my original article…

Block presents two arguments for why we shouldn’t take Tuteur seriously. The first is that she is no longer practicing …Block offers no evidence to dispute her interpretation of existing data. Nor does she explain why Tuteur’s retirement renders her impressive medical background irrelevant.

It was Tuteur who found serious flaws in a widely-cited study published by home-birth advocates Kenneth C. Johnson and his wife, Betty-Anne Daviss, in the British Medical Journal, that purported to show home birth’s safety. In response, Johnson and Daviss self-published a new analysis with updated data—a tacit admission that Tuteur’s criticisms were valid. (Tuteur, as I explained, disputes the methodology of their new, non-peer reviewed analysis as well.) She is an important voice in this debate, whether Block likes it or not.

Moreover:

… I also quoted Martha Reilly, chief of Women’s and Children’s Services at McKenzie-Willamette Medical Center near Eugene, Ore., a place where home birth is particularly popular. Reilly told me that every ob-gyn she works with has treated a woman rushed in after a home birth gone awry, her baby dead or severely injured. Block essentially accuses her of lying, though according to Reilly she didn’t bother to call her. “The Department of Health reports 102 planned home births in Lane County in 2010,” writes Block. “Reilly’s claim is improbable given that the odds are in the per-thousand range, though it’s perhaps indicative of how polarized some providers are on this issue.” But Reilly didn’t claim that all these disasters happened in one year. Nor is there any reason to assume, as Block does, that none of them came from surrounding counties.

And typical of Block’s “bad faith approach”:

… She quotes one “Melissa Cheney,” an “anthropologist at Oregon State,” who claims to have found that doctors spread unsubstantiated rumors about home-birth deaths. In fact, the anthropologist’s name is spelled Melissa Cheyney, and in addition to her post at Oregon State, she is a licensed midwife and head of the division of research at the Midwives Alliance of North America. Cheyney is a major figure in the pro-midwifery community, not an objective academic observer.

In addition:

…[Block] cites studies from Canada, the U.K., and the Netherlands … I explained, in my original piece, why it doesn’t make sense to compare home-birth midwifery in the United States, where training and regulation are incredibly lax, to the practice in countries where it’s deeply integrated into national health services. For the sake of brevity, I didn’t go into detail. Let me do so now, focusing on Holland, a country American home-birth advocates love to reference. (You may also want to read Lindsay Beyerstein of In These Times on the same subject.)

… [I]t’s not entirely clear just how well the Dutch system really works. A 2010 study of Holland from the British Medical Journal found that the babies of low-risk mothers cared for by midwives had a higher death rate than the babies of high-risk women who delivered in hospitals. The study also pointed out that the Netherlands has one of the highest perinatal morality rates in Europe. “Whether the Dutch obstetric-care system contributes to this relatively high mortality remains unclear,” it says.

Goldberg offers a powerful indictment of homebirth advocates:

… The home-birth movement seems to be driven by a quasi-religious naturalist ideology that denies the danger that’s been inherent in childbirth for most of human history. It cherry-picks studies, distorts facts, and attacks its critics in a way that reminds me of my many years reporting on the Christian right. (my emphasis)

As to the charge that those who report on the data about the risk of neonatal death at homebirth:

Women have a right to adhere to the home birth movement’s ideology, and as far as I’m concerned they have a right to have their babies anywhere they choose. But they also have a right to know that giving birth at home has the potential for as much danger and trauma as anything in Block’s book about the horrors of hospitals. They have a right to weigh the very real risk of an unnecessary C-section against the risk of a dead baby, which is much smaller but, to many mothers, much more grave.

That’s not trying to scare women. It’s being honest with them.

They must be really frightened. They’ve rolled out the big guns.

After years of advising each other “Don’t listen to Dr, Amy,” they’ve turned to advising the general public not to listen to me. How else to explain Jennifer Blocks’s charming collection of ad hominems masquerading as an article of Slate. Entitled How to Scare Women, the piece carries the subtitle “Did a Daily Beast story on the dangers of home birth rely too heavily on the views of one activist?”

The piece in The Daily Beast to which Block refers is Home Birth: Increasingly Popular but Dangerous, which included the latest statistics of homebirth deaths as well as stories of two terrible, senseless, entirely preventable deaths. Block more or less dismisses the stories, but doesn’t even bother to dismiss the statistics. She can’t; they’re accurate and damning as she surely knows. So instead she tries to discredit me in the hope that she can divert the attention of homebirth advocates from the data itself. It’s a pretty despicable tactic, especially when you consider that it depends on the belief/hope that homebirth advocates are so gullible and unsophisticated that they cannot tell them difference between the two.

Fortunately, it addition rehearsing the same old ad hominems that are so silly that I have been satirizing them for years (She let her license lapse! She quite writing for Science Based Medicine!), Block helpfully links to a variety of blog posts that I have written. I’m not sure why she did it, because it thoroughly undercuts her efforts to discredit me by giving readers access to what I have actually written. I’m not sure whether she thinks less of me or her readers; me because she doesn’t find the pieces persuasive or her readers because she assumes that they won’t read them, understand them, and be convinced by them.

I left a comment on the post:

I suppose I should be flattered that Ms. Block believes that women decide whether or not homebirth is safe depends on what they think about me. I, on the other hand, feel very strongly that women are capable of looking at data and scientific evidence for themselves and my chief task is simply to make it accessible to them.

If you get past the various ad hominem attacks on me, you may note that Ms. Block has not challenged the fact that the latest CDC data shows that homebirth with a non-nurse midwife has a mortality rate 600% higher than comparable risk hospital birth. She has not challenged the high and rising rate of perinatal death at planned homebirths attended by licensed homebirths, rates that are double or triple the rate for Colorado as a whole, including premature babies and high risk women.

Women have a right to give birth at home, but they can’t make an informed decision if they don’t have complete and accurate information. Ms. Block is welcome to continue to write about me; I’ll keep writing about the data and I’ll keep trusting women to decide for themselves how to act on that data.

Jennifer Block and I do agree on one thing however; the article in The Daily Beast is scary. The scary part, though, is the mass of data that shows that homebirth with a non-nurse midwife dramatically increases the risk of neonatal death. It is deeply unfortunate, that Block, like most professional homebirth advocates, chooses to ignore that data and resorts to what amounts to little more than name calling in attempt to get others to ignore it as well.

I have a suggestion for how we might resolve the impasse. I have repeatedly challenged Jennifer Block to publicly debate the safery of homebirth. Slate could serve as the forum for a print debate about the state, national, and international statistics on homebirth, and the growing body of scientific evidence. Would the folks at Slate be willing? How about it, Jennifer? I’m ready any time; how about you?

Janet Fraser, the leading Australian exponent of unassisted childbirth lost one of her own children at homebirth. You might be excused for thinking that this the death of one of her own children is the most traumatic loss that Fraser has experienced, but you’d be wrong. According to Fraser, she was more traumatized by the loss of her ideal birth “experience” when her healthy first child was born. Apparently, the coroner didn’t see it that way. Indeed, the brief coronial report exoriates Fraser for her fantastical beliefs and her chilling narcissism.

The report summarizes what happened:

1. This is an inquest into the death of Roisin Fraser who was born and, within minutes, died on 27 March, 2009. Roisin was the daughter of Janet Fraser and Trevor George Stokes. There are two older children of that relationship, still living with their mother. Ms. Fraser is a leading tigure in a movement called “Joyous Birth” advocating free birthing which is a method of home birthing where, except in circumstances of quite dire emergency (and, sometimes, even in those circumstances.) the intervention of medical practitioners, nurses and hospitals and, often, as in Roisin’s case, that of midwives is avoided.

Cause of Death

2. Practicing free birthing principles and with the assistance of her partner, Trevor Stokes, and a friend, Marianna Duce, both unqualiied in medicine, nursing or midwifery, Janet Fraser was delivered of Roisin at her home at about 1.12am on 27 March, 2009. Roisin was pronounced dead at Royal Prince Alfred Hospital, Camperdown at about 2.27am on the same day.

Why did Roisin die? The coroner, Scott Mitchell, found:

Roisin Fraser, who was born on 21 March, 2009, died moments later at her parents then home at … NSW of an hypoxic episode probably a direct or indirect consequence of cord entanglement encountered during delivery where, at her mother’s insistence, mother and chlld were unassisted by any person qualified ln the areas of medicine, nursing or midwifery.

In practical terms, Roison Fraser died because of the inability of Fraser’s attendants and Fraser herself to resuscitate the baby:

Essentially, Ms. Fraser was quite unprepared for what happened. There was not even a hard, flat surface available on which Roisin could be placed for resuscitation so these three amateurs – Ms. Fraser, Mr. Stokes and Ms. Duce, first placed the child on the rim of the inflatable pool and, when that proved unsatisfactory, used a chair. They were unable to abandon the chair and place Roisin on the floor in order effectively to administer CPR there because, the placenta not having been delivered, “that was as far as she would reach. ” Evidently, it occurred to nobody present to clamp and cut the cord and, anyway, Ms. Duce told the inquest, she had not been aware of the ready availability of any equipment to enable her to do so. According to Ms. Duce, further difficulties were encountered in administering CPR because Roisin was slippery and difhcult to hold and, evidently, it did not occur to anybody to wrap her in a towel although there were towels nearby.

But the real reason for Roison’s deaths was Janet Fraser’s personal beliefs:

The Joyous Birth website controlled by Ms. Fraser offers advice to expecting or expectant mothers some of which is couched in temrs which even Ms. Fraser, its principle author, described as “intemperate.” Visitors to the site are warned ofa “giant birthing industry” against which Ms. Fraser has dared to pit “her arrogant feminine self” “Hospitals are dangerous” and “Obstetricians” she wams “are surgeons at heart
..whose skill set is rarely needed.” Mothers to be are advised that ‘size estimates are a crock” and that “your pelvis works perfectly.” “Monitoring” is described as “you with a bed strapped to your back, monitors wrapped around your be/LY, probably a scalp monitor shoved through your vagina and screwed into your baby’s head thus preventing you from moving around and actually birthing.” Women are warned that their obstetrician is liable to “manoeuvre” them into surgery when they really don’t need it- “there’s a basic contradiction in going to a surgeon to avoid surgery isn’t there?” which, they are reminded, will ‘guarantee your uterus has more than a hole, it will have a big slice that someone will put their hands in and rip open.”

According to Ms. Fraser as she is reported on the Joyous Birth website, “hospitals (places for sick people) have no business dealing with nonnal, physiological birth (perfonned by healthy women) but now that they do, they continue to peddle their own importance and kid us that we need them… …Surgeons create repeat business for themselves in a way that, if it was another industry, would be seen for what it was –
shameless money making… …So it doesn’t matter if she looks for another surgeon or hospital (they’re run by surgeons, did you realise that?”

The coroner explains:

This propaganda served up by Joyous Birth, of which the foregoing is only a taste, appears typical of an intention to convert women who visit the site to the view that medical and hospital involvement in their pregnancies and births is undesirable and contrary to their interests as women and mothers and that professional involvement, including the involvement of professional midwifes, should be kept to a minimum.

The coroner concludes:

This is a free country and Ms. Fraser can use the Joyous Birth website to proselytise as she sees fit… [Her views] are wrong views, extravagantly expressed and quite insensitive to the harm they may do to others, whether inexperienced mothers or children like Roisin whose chance of life was so unnecessarily put at risk. lf they seem intellectually valid or politically attractive to Ms. Fraser, she might give thought or more thought to the effect they may well have on children like Roisin.

Ever wonder why your pelvic and abdominal organs don’t simply fall out? Probably not, but if you did stop to wonder about it, you might have concluded that it is the bones of the pelvis that keep everything inside. That’s only part of the answer. In fact, the main structure that keeps everything inside is the pelvic floor.

The pelvic floor is the name for the group of muscles that overlap each other across the bottom of the pelvis. It acts like a hammock to suspend the pelvic organs and hold them in place. The pelvic floor looks like this:

Just like a hammock, it can become torn, stretched and worn. In fact, it can become so torn, stretch or worn that the pelvic organs do begin to fall out. That is known as prolapse.

What is prolapse? Why does it happen? How is it related to childbirth? And how do tears of the pelvic floor compare to and impact prolapse? To answer these questions, it helps to visualize the pelvic floor as a hammock made of spandex fabric, rather like the hammock in the photo above. Now imagine that the hammock has two small holes in it to let the rain flow and the leaves fall through. Two relatively small holes won’t compromise the strength of the hammock.

What happens in pregnancy and childbirth? Pregnancy is the equivalent of a great weight on the hammock for a prolonged period of time. It is easy to see how that could stretch the hammock. Perhaps the fabric will return to its original shape and size, but if you leave the weight on the fabric long enough, or repeat the application of weight for long periods many times, the fabric will ultimately stretch and may not completely return to the previous shape. That’s similar to the impact that pregnancy has on the pelvic floor.

How about childbirth? Imagine that a bowling ball is forced through one of the small holes in the hammock. A number of things may happen. The fabric may be stretchy enough to accommodate the bowling ball and to return to its original shape after the bowling ball passes through. It’s also possible that the bowling ball will pass through, but the hole is permanently stretch. That’s equivalent to a larger vaginal opening after childbirth. Finally, imagine that in order for the bowling ball to pass through, the fabric tears. That’s the equivalent of a vaginal tear. The opening is now permanently larger. A small vaginal tear may heal on it’s own, but if enough tissue is torn, it may not heal back together properly and the woman will be left with a gaping vagina.

A fourth degree vaginal tear is the equivalent of a tear in one hole of the hammock extending all the way into the second hole, leaving a big rent in the fabric. That will never heal by itself, and, it will leave the woman with bowel incontinence.

What about prolapse?

Prolapse is different but related.

Imagine that the hammock is used for the next twenty five years. It is almost inevitable that the fabric will get stretch and worn. The holes in the fabric, whether they are still in orignal shape, already permanently stretch, or actually torn, will widen still further. The same thing happens in the pelvic floor and the process accelerates as estrogen drops and disappears in menopause. Now the pelvic organs may begin to literally fall out.

When the bladder falls out (prolapses), it is called a cystocele. When the uterus false out it is known as uterine prolapse. Since the bladder is so close to the uterus, when the uterus falls out the bladder usually comes down with it. In either case, when the bladder begins to fall through the pelvic opening, women can lose control of their bladder. This kind of incontinence is known as stress urinary incontinence (SUI). Things are usually okay in most circumstances, but when a woman coughs, sneezes or laughs, intra-abdominal pressure is increased and the bladder is pushed through the opening in the pelvic floor and urine is forced out. Stress urinary incontinence is extremely common in women in their 50’s and older.

If the rectum falls out, it is called a rectocele, and it can affect bowel continence.

What’s the relationship between tears and prolapse? It’s easy to envision that if the opening in the pelvic floor is already stretched or torn to larger than original dimensions, the stretch and wear of age is only going to make the problem worse. That’s why vaginal birth puts a woman at much greater risk of prolapse. Having a C-section instead of a vaginal delivery does not guarantee that you will not ultimately develop a prolapse of one form or other. After all, simply being pregnant can permanent wear the muscles of the pelvic floor. However, vaginal delivery adds additional stretching, and possibly tearing to what would have happened anyway, making prolapse much more likely.

This explains the original impetus for episiotomy. Until the past few decades, there was not much that could be done for prolapse so doing anything possible to avoid it seemed like a good idea. The thinking behind episiotomy was to cut a straight “tear” before the muscles of the pelvic floor were stretched to their maximum and before they tore of their own accord. Unfortunately, in practice it did not work that way. Rather than protecting the muscles of the pelvic floor, the most common type of episiotomy (median episiotomy) actually made more extensive damage more likely. Hence the practice of episiotomy has been largely discarded. However, the idea was not a foolish one, and was worth trying.

Obviously this is a vastly simplified view of a complex anatomical issue, but hopefully it will help readers to better understand tears and prolapse, why they occur, and their ultimate consequences.

I’ve written before about homebirth midwives who don’t know how to suture and therefore tell women with serious perineal tears that they don’t need stitches. Here is an example of the terrible result:

I gave birth at home to a beautiful and healthy 8 pound 4 oz baby in Feb. 2012… After birth I had fecal incontinence (gas) but thought it was really because of the stretching of the muscles after birth. Right after birth my two midwives checked me and said it was just 2nd degree lacerations and that I was ok, no need to stitch, just keep my legs together and it will heal by itself.

As I’ve explained previously, major perineal tears will not heal by themselves:

A torn sphincter will not heal itself because the torn ends are usually far apart from each other after the muscle fibers retract. The superficial layers of the tear will heal and it may look like everything is normal, but the woman will not be able to control her bowel function and will definitely need an involved surgical repair under anesthesia.

The story continues:

Four months later, I went to the OBGYN because I thought there was something wrong with me. The opening was just too big and literally I dont have a perineum.

The obgyn told me I had 4th degree lacerations and I needed a procedure called sphincteroplasty and that I would never be able to have any babies vaginally any more. I left the office crying hysterically and called my midwife. I told her that didn’t sound right and she agreed, that Dr. must’ve been wrong. My midwife referred me to another MD, that was midwife friendly.

But the result was the same:

I visit the referred MD and he agrees that I need a sphincteroplasty and referred a colo-rectal [surgeon]. I go to the colo rectal. Not only I have a 4th degree laceration that needs to be repaired with an sphincteroplasty but also a recto-vaginal fistula. In order to have success in this delicate surgery I need to previously have a colostomy surgery before the sphincteroplasty surgery, to open the colostomy and after to close it in order to divert the feces from the area of the surgery, to avoid infection…

What is a 4th degree perineal tear?

A fourth degree tear extends down from the bottom of the vagina, through the tissue separating the vagina from the rectum, through the sphincter (muscle) that controls bowel continence, right through into the rectum itself. The result is that the vagina and rectum form one continuous space.

Why was suturing absolutely necessary?

… [B]ecause the rectum itself has been torn, the possibility exists that the tear may heal improperly and leave a hole (fistula) between the vagina and rectum with consent leaking of feces from the vagina.

That’s exactly what happened to this unfortunate mother. Now she needs 3 separate surgical procedures: surgery to create a diverting colostomy; surgery to repair the rectum, rectal sphincter, and entire perineum; and surgery to reconnect the colon diverted in the colostomy.

As the mother explains:

Recovery time is 4 months or more depending if there is no complications. My family is all abroad, I am by myself SAHM, I am 29 years old and my baby is 5 months old. I’m not going to be able to take care of him while I’m having all these horrible procedures because my midwife couldn’t identify that I had a 4th degree tearing…

Moreover, all future births will need to be C-sections because a vaginal delivery would destroy the repair.

The mother feels devastated:

I am soo sad and upset, I have been crying for the last week. Every time I see my baby I wonder about the risk of undertaking this type of surgeries… I don’t want to have a colostomy for 2 months. I don’t want a scar in the middle of my stomach. I have never had any kind of surgery. This is all very unnecessary. If she could’ve just identify my 3rd-4 tearing and take me right to the emergency room I wouldn’t be tonight telling you this horror homebirth story.

I was sold on the homebirth movement, not anymore. Go with … a professional that can identify the type of laceration you have, one who can identify emergencies and finally a professional that keeps your perineum intact. Your perineum is important in your reproductive life. I’m so lost.

Babies are not the only ones hurt by homebirth.

Homebirth midwife Evelyn Muhlhan, CNM was suspended as the result of 5 separate homebirth disasters, including a baby who died and Enzo Martinez, a baby rendered permanently brain injured.

Enzo’s parents sued and yesterday were awarded $55 million … from the hospital.

Why the hospital?

It will cost an incredible amount of money to care for Enzo and Muhlhan herself is judgment proof, since she apparently carried no insurance. Hmmm, who else was involved in the case that has lots of money? Ahh, yes, the hospital; Johns Hopkins hospital carries lots of insurance. Let’s sue them. Who’s actually responsible for Enzo’s brain injury? Who cares?

Enzo’s case was detailed in the suspension order issued by the Maryland Board of Nursing:

On or about April 14,2010, the Board received a complaint from … Director of Labor and Delivery and … Director of Gynecology and Obstetrics, at Hospital B. According to the complaint, between March 25th and 26th, 2010, Respondent failed to follow the standard of care in her management of an attempted home birth by:

I. Utilizing Intramuscular Oxytocin to stimulate labor in a term pregnancy;
II. Using fundal pressure in the second stage of labor to attempt to cause descent of
the fetus;
III. Using vaginal chlorhexadrine, rather than intravenous penicillin, in labor to treata known group B beta hemolytic strep vaginal carrier to prevent early onset GBS neonatal sepsis;
IV. Misdiagnosing fetal station resulting in an unnecessary episiotomy. The physical exam on admission to Hospital B was a fetus impacted in the vagina at + 1 station which was incompatible with the report that the fetus had been crowning when the episiotomy was performed…

… Patient B delivered a male infant (“Baby B”) by LSTCS, with a vertex fetal presentation and occiput posterior (“OP”) position at birth. The APGAR scores were 1 at 1 minute and 5 at 5 minutes and cord/Initial blood gas was ph 7.1; pC02 63; p02 10; BE -13. Baby B was limp and cyanotic on delivery with nuchal cord x 1, required PPV for 3 minutes before being transitioned to CPAP. Baby B was transported to the NICU on CPAP with diagnoses of Hypoxic Ischemic Encephalopathy and Seizure disorder.

Baby B was transferred to a pediatric rehabilitation hospital on April 21, 2010.

In other words, Muhlhan was horribly negligent in caring for this women and the hospital saved Enzo’s life. Enzo’s parents know this and do not dispute it. They insist that the hospital didn’t save Enzo’s life fast enough, contending that there was a delay in performing the necessary C-section.

How did the jury decide that it was a purported delay at the hospital that resulted in Enzo’s injury and not the egregious malpractice of Evelyn Muhlhan? It was easy. Enzo’s parents’ lawyers successfully argued to disallow any evidence of Muhlhan’s negligence.

As the court records show:

Plt [Plaintiff’s] motion in limine to preclude any refence [sic], testimony or argument that ceritified nurse-midwife Evelyn Muhlhan Deviated from the standard of care and to preclude Loraal Patchen, CNM and Carolyn Gegor CNM from testifying is hereby heard and granted.

And:

Plt motion in limine to preclude any reference, testimony and/or evidence of Maryland Board of Nursings’ orer for summary suspension of Nurse-Midwife Evelyn Muhlan is hereby heard and granted.

And just to be on the safe side:

Plt omnibus motion in limine regarding certain irrelevant and prejudicial evidence is hereby heard and agreed upon as it relates to Group B Streptococcus, is agreed upon as it relates to genetic cause of E.M. injuries and is granted as it relates to deviation from standard of care not casually linked to array of harm (episiotomy).

So in a case in which the homebirth midwife violated every standard of care and managed a few creative forms of negligence that haven’t been seen before, including attempting a home induction with pitocin and cutting an episiotomy before the baby’s head was anywhere near delivery, the jury never heard about any of it.

Apparently, as far as the jury knew, Enzo’s mother arrived at the hospital in labor, had a C-section and gave birth to a baby with profound hypoxic ischemic encephalopathy. It could have been (and probably was) the result of multiple hours of labor at home and the egregious malpractice of homebirth midwife Evelyn Muhlhan, subsequently suspended from practicing specifically because of her negligent actions. But the jury was not allow to hear about Muhlhan and her actions. It is hardly surprising, then, that they blamed the hospital.

How did the jury reach this conclusion. As the newspaper article explains:

Donald H. Beskind, a professor at Duke University School of Law … said juries are typically influenced by three main factors when deliberating on malpractice cases: the degree to which it’s clear who was at fault for the negligence, what money would do to improve the plaintiffs’ quality of life, and whether the defense did something to offend the jurors, such as attack the plaintiffs.

It’s pretty clear how the money will help care for Enzo, and we don’t know whether or not the defense did something to offend the jurors. But how on earth was the jury to decide who was at fault when the evidence that Muhlhan was at fault was excluded before the trial even started?

Hospitals and doctors know that when a brain injured child comes to court, sympathy for the child and his parents usually overwhelms any effort to rationally attribute blame. That’s why these cases are typically settled even when the evidence favors the defendant. It’s simply too risky to leave these cases to a jury who may vote with their hearts and not their heads.

Therefore, the fact that the hospital and its insurer went ahead with the trial suggests that they thought not merely that they were not at fault, but that the evidence that they were not at fault was overwhelming. They were wrong and the impact will extend beyond this case:

Stephen L. Snyder, a high-profile Maryland litigator, said the judgment has the potential to further discourage courtroom battles in malpractice cases. Already, most malpractice cases settle before trial, he said.

“If this case is a wake-up call to the hospitals and insurers, they may be more willing to bring closure to cases sooner and more efficiently without marring their reputation, which ultimately would unburden the courts,” Snyder said.

The hospital plans to appeal the verdict, and it may yet be overturned by appeals judges who will consider only the legal issues and the facts of the case.

It is natural to feel sorry for Enzo. He will have to live the rest of his life profoundly disabled because his mother wanted a homebirth.

And it is difficult not to feel sympathy for Enzo’s parents who wake up every day and deal with the catastrophic results of their choice. They need money to care for Enzo.

That may explain why they chose to sue the hospital with deep pockets when it was the malpractice of the negligent homebirth midwife that led to Enzo’s injuries, but that doesn’t make it right.