The National Institutes of Health released a comprehensive review of outcomes of vaginal birth after cesearean (VBAC). They study, entitled Vaginal birth after cesarean: new insights by Guise et al. is a comprehensive review of the literature.

In analyzing maternal and perinatal mortality, The authors found:

Overall rates of maternal harms were low for both TOL and ERCD. While rare for both TOL and ERCD, maternal mortality was significantly increased for ERCD at 13.4 per 100,000 versus 3.8 per 100,000 for TOL. The rates of maternal hysterectomy, hemorrhage, and transfusions did not differ significantly between TOL and ERCD. The rate of uterine rupture for all women with prior cesarean is 3 per 1,000 and the risk was significantly increased with TOL (4.7/1,000 versus 0.3/1,000 ERCD). Six percent of uterine ruptures were associated with perinatal death… Perinatal mortality was significantly increased for TOL at 1.3 per 1,000 versus 0.5 per 1,000 for ERCD.

In other words, elective repeat cesarean delivery (ERCD) increases the rate of maternal death compared to trial of labor (TOL) by approximately 9/100,000. However, TOL increases the risk of perinatal death by 80/100,000.

Let’s look at the findings in detail.

Maternal death

Overall, the strength of evidence regarding the rate of mortality for women with a prior cesarean delivery is high with good consistency and precision. While maternal mortality is rare .., the risk of maternal mortality is significantly increased with ERCD. When combining the TOL group across all studies, the risk of maternal mortality is found to be 0.0038 percent (95 percent CI: 0.0009 to 0.0155 percent). The combined risk for ERCD group across all studies is 0.0134 percent (95 percent CI: 0.0043 to 0.0416 percent). This translates to 3.8 per 100,000 for TOL (95 percent CI: 0.9 to 15.5 per 100,000) and 13.4 per 100,000 for ERCD (95 percent CI: 4.3 to 41.6 per 100,000)…

While rare for both TOL and ERCD, compared to ERCD, the overall risk of maternal death associated with TOL is significantly lower (RR, 0.33, 95 percent CI: 0.13 to 0.88; p=0.027). Using 0.0134 percent as the baseline risk for ERCD, the calculated risk difference is −0.0090 percent (95 percent CI: −0.0117 to 0.0016 percent), translating to 9.0 less deaths per 100,000 (95 percent CI: 1.6 to 11.7 less deaths per 10,000) from the TOL group…

Uterine rupture

… Among these four studies totaling 47,202 patients, there were 154 uterine ruptures; 96 percent (N=148) of which were incurred by the TOL group… Within these four studies, the combined risk of uterine rupture for women undergoing a TOL is 0.47 percent (95 percent CI: 0.28 to 0.77 percent) and 0.026 percent (95 percent CI: 0.009 to 0.082 percent) for women undergoing an ERCD…

… [T]he occurrence of uterine rupture for TOL remains relatively unchanged at 0.46 percent. Among TOL studies, the occurrence of uterine rupture is significantly higher for studies limited to term patients compared with studies including patients of any GA (0.78 versus 0.32 percent, p=0.033)…There were no uterine ruptures among women who experienced ERCD without labor for any direction of incision…

Morbidity and mortality of rupture

… [T]here were no maternal deaths due to uterine rupture in any of the eight studies. The risk for perinatal death in the event of uterine rupture ranged from 0 to 20 percent with a pooled risk of 6.2 percent and the highest risk experienced by the TOL group…

Overall, evidence regarding the rate of uterine rupture for women with a prior cesarean delivery is moderate in strength … Compared with women undergoing an ERCD, women undergoing a TOL have a significantly higher risk of uterine rupture (RR 20.74, 95 percent CI: 9.77 to 44.02; p<0.0010)... To date, there have been no maternal deaths reported because of uterine rupture, and the risk of perinatal death due to uterine rupture is similarly low at 6.2 percent. However, the risk of hysterectomy due to uterine rupture is an important consideration for women planning VBAC, with rates ranging from 14 to 33 percent...

Perinatal death

… The risk of perinatal mortality was significantly higher for TOL as compared with ERCD (RR 1.82; 95 percent CI: 1.24 to 2.67; p=0.041). Using 0.05 percent as the baseline risk for ERCD, the calculated risk difference was 0.41 percent (95 percent CI: 0.012 to 0.08 percent) which is equivalent to .41 more deaths among women who attempt TOL…

Neonatal death

… The risk of neonatal mortality was significantly higher for TOL compared with ERCD with a calculated risk difference of 0.058 percent (95 percent CI 0.019 to 0.117 percent), which is equivalent to .58 additional perinatal deaths per 1,000 for TOL.
Subsequent babies

Two studies were reviewed to determine the risk of stillbirth in subsequent pregnancies in women with a prior cesarean delivery. These studies produced conflicting results with one study showing that prior cesarean increases the risk for unexplained stillbirth in next pregnancy and the other study showing no difference in risk for stillbirth in the next pregnancy…

The authors summarize their findings:

One of the major findings of this report is that the best evidence suggests that VBAC is a reasonable and safe choice for the majority of women with prior cesarean. The occurrence of maternal and infant mortality for women with prior cesarean is not significantly elevated when compared with national rates overall of mortality in childbirth. The majority of women who have TOL will have a VBAC, and they and their infants will be healthy. However, there is a minority of women who will suffer serious adverse consequences of both TOL and ERCD…

What are we to make of these findings?

The absolute level of risk for both TOL and ERCD is low. ERCD is associated with a risk of maternal death of 9/100,000. Although the cesareans are classified as “elective.” that does not mean that the women who chose them were good candidates for VBAC, so it is not clear how many of these C-sections were truly elective. TOL is associated with a perinatal death rate of 80/100,000. Although there is a decreased risk of maternal death, there is a dramatically increase rate of uterine rupture rate of 460/100,000. Since many of those women (14-33%, or 64-153/100,000) will go on to have a hysterectomy due to the rupture, TOL increases the risk of serious maternal morbidity.

This literature review essentially confirms what we already knew. VBAC increases the rate of perinatal death, uterine rupture and subsequent hysterectomy, while ERCS has a higher rate of maternal death. albeit an order of magnitude smaller than the VBAC associated increased risk of perinatal death.

No less a medical authority than January Jones, star of the AMC series Mad Men, has announced that she ate her child’s placenta.

As HuffPo reports:

Jones … told People that taking the capsules isn’t “witch-crafty” and she recommends it to all moms. Besides, she adds, humans are the only mammals who don’t do it.

Eating the placenta is a relatively new wacky practice among natural childbirth and homebirth advocates. And as can be expected of most practices exclusive to NCB and homebirth, it displays the full spectrum of ignorance: ignorance of obstetrics, ignorance of history, and this case, ignorance of mammalian biology.

Placentophagia is the scientific term for eating the placenta. Yup, eating the bloody, rubbery placenta. You can eat it raw, and some proponents insist that this provides the most “benefits.” But for those who are more fastidious, you can dry it and put it in capsules to eat later.

Why would you do that? Because, like January Jones, you are gullible, of course.

Placenta Benefits.info provides supplies and services to help you prepare your baby’s placenta. (Wacky childbirth practices almost always cost money and are a source of income for childbirth “professionals.”) What are these purported benefits that Placenta Benefits is extolling?

Why should I take placenta capsules?
Your baby’s placenta, contained in capsule form, is believed to:

*contain your own natural hormones
*be perfectly made for you
*balance your system
*replenish depleted iron
*give you more energy
*lessen bleeding postnatally
*been shown to increase milk production
*help you have a happier postpartum period
*hasten return of uterus to pre-pregnancy state
*be helpful during menopause

Now that you’ve read the fantasy, let’s look at the reality.

Is eating the placenta natural?

Sure … if you are a rat, and maybe even if you are a lemur. But how about if you are higher order primate, or a human being? Eating the placenta is variable among higher order primates, and virtually never occurs among humans.

Indeed, the anthropological literature dates the first sighting to an indigenous group of California homebirth advocates (I kid you not). In Consuming the inedible: neglected dimensions of food choice, MacClancy and colleagues report:

… In association with the natural childbirh movement from the 1960’s placentophagia was taken up in some ‘Western’ societies, especially in California, on the basis that it was ‘natural’, as ‘all’ mammalian species eat the placenta. The problem with this is that not all mammals are regularly placentophagous and our closest primate relatives also are not placentophagous… [M]odern placentophagia is based on an inaccurate idea of making the human birthing process more ‘natural’.

In other words, eating the human placenta is not natural and it is an affectation dreamed up by California hippies.

Can eating the placenta replenish depleted iron and give you more energy?

In the world of cooking, the placenta would be considered an “organ meat” and could theoretically improve iron levels. In fact, it may do so in species that are regularly placentophagous. Of course, eating any part of any human being could probably do the same. And though it is theoretically possible, there are no studies that have shown that it occurs.

Can the placenta decrease postpartum bleeding?

In other words, does the placenta contain utero-tonic substances like oxytocin? There’s no reason to believe it does and considerable reason to believe it does not.

The purpose of the placenta is to interface with the mother’s circulation and thereby transfer oxygen and nutrients. Contractions of the uterus interfere with that function (when the uterus contracts, exchange cannot take place) and may cause the placenta to shear away from the wall of the uterus (an abruption). There is precisely ZERO reason to believe that eating the placenta will prevent postpartum bleeding. In fact, Placenta Benefits.info, which has a full page of bibliography salad masquerading as supporting research, can’t manage to find even a single paper on the purported utero-tonic effects of placenta.

Can eating the placenta increase milk production?

In other words, is the placenta a galactagogue? I could find only two papers on the subject. One was published in the BMJ … in 1917. The other, quoted by Placenta Benefits.info is Placenta as Lactagagon published in 1954 by Soykova-Pachnerova in the journal Gynaecologia. The study is poorly done and has never been replicated.

The bottom line is that there is no evidence that eating the placenta increases milk production.

Can eating the placenta prevent postpartum depression?

No. According to Pec Indman, a psychotherapist who specializes in postpartum mood disorders:

Although there has not been one study (not even poorly done) about the effects in humans on placental ingestion, the claims are that it prevents the blues and PPD …which contributes the spread of misinformation about perinatal mood and anxiety disorders. There is no evidence that the freeze drying processing of placental tissues maintains the integrity of the hormones, protein, and iron. There is no evidence about any part of this process to warrant a recommendation.

Indman’s comment about the integrity of placental components highlights another important issue. There is no evidence that the placenta contains hormones that are biologically active in increasing milk supply, decreasing postpartum bleeding or improving postpartum mood. But even if the placenta did contain such hormones, you’d still have to show that they survived biologically intact, did not get destroyed by the acid in the stomach, existed in a form that could be absorbed in the intestine, and are absorbed in a form that could be utilized by human cells.

When it comes to placentophagia, natural childbirth and homebirth advocates are batting zero, as usual. Eating the placenta is NOT a natural process for humans. Indigenous peoples around the world did NOT eat the placenta. There is NO evidence that eating the placenta improves iron stores. There is NO evidence that eating the placenta prevents postpartum bleeding. There is NO evidence that eating the placenta improves milk supply. And there is NO evidence that eating the placenta prevents or treats postpartum depression.

There is one thing that eating the placenta reliably does, though. It does highlight the fact that natural childbirth and homebirth advocates are gullible and woefully uneducated about human childbirth.

Adapted from a piece that first appeared in November 2010.

Here’s a little unsolicited advice for natural childbirth and homebirth advocates who are constantly complaining about obstetric recommendations that they don’t understand.

If you don’t understand an obstetric recommendation:

1. Don’t conclude that your midwife, your doula, Henci Goer, or you have a better grasp on the scientific evidence than obstetricians do.

In the first place, neither your midwife, your doula nor you have read the obstetric scientific literature, so you literally have no idea what it says. And Henci Goer has read the literature, but she quotes it extremely selectively and in ways that are deliberately misleading. That’s how she makes her money: flattering women who are clueless into believing they are “educated.”

Any truly educated person knows this already. Educated people tend to have great respect for the education of other people. You won’t find too many doctors giving legal advice, or architects giving advice on dentistry. The classic sign of an uneducated person is their dismissal of others who have more education.

If you don’t understand an obstetric recommendation:

2. Don’t conclude that your obstetrician made it up in order to get to his golf game.

Newsflash, this is the 2010’s,not the 1950’s. The majority of obstetricians are women and most of them don’t play golf. Moreover, in case you haven’t noticed, a major proportion of obstetricians are on salary and work fixed hours. They aren’t going to play golf or do anything else while they are on call; they will be in the hospital anyway.

I’m not aware of a single study that demonstrates or even suggests that obstetric recommendations have their genesis in the desire to get to the golf course or anywhere else.

If you don’t understand an obstetric recommendation:

3. Don’t conclude that anyone is making money from that recommendation.

As mentioned above, a major proportion of obstetricians are on salary. Their compensation is not affected by whether you have a C-section, an induction, or any interventions. Entire countries have put doctors on salary (e.g. England) and their C-section rates have skyrocketed, too.

If you don’t understand an obstetric recommendation:

4. Don’t assume it is “defensive medicine.”

This is apparently going to come as a real shock to some NCB and homebirth advocates, but doctors (and nurses) are legally and ethically required to follow professional practice standards. It’s not discretionary. They must make recommendations in keeping with the latest scientific evidence, not the latest NCB fads.

What is “defensive medicine” anyway? It’s the attempt to prevent you or your baby from dying or being seriously injured. It is as “defensive” as seatbelts or flossing your teeth. It doesn’t guarantee good outcomes, but it makes them more likely. The fact that a recommendation turns out to have been unnecessary is no different than when it turns out that your car wasn’t involved in a crash today. It wasn’t “unnecessary” to wear your seatbelt.

If you don’t understand an obstetric recommendation:

5. Don’t assume that the midwife, doula, neighbor or a stranger on an internet message board who is advising you to ignore that recommendation has your best interests at heart. More often than not, they have THEIR best interests at heart. Midwives and doulas want more than anything else to get paid. It does not take a rocket scientist to figure out that midwives and doulas will tell you to ignore recommendations that they cannot get paid for (since they don’t know how to implement those recommendations). Even worse, they may lose you as a client (and your fee) if you decide to follow your obstetrician’s recommendation.

Your neighbor and the stranger on an internet message board may not have your interests at heart, but for an entirely different reason. They need to have their own choices mirrored back to them in order to boost their self esteem. They are invested in having you copy whatever they did.

There are a lot of things wrong with both natural childbirth and homebirth advocacy. Of course the principle fault is that most of it is not supported by the scientific evidence, but possibly the second largest fault is that its purveyors make money by creating mistrust and suspicion of professionals who have far more education, training and experience than they do. It’s obvious why they do it; they want you to discount the obvious benefit of having a highly educated, well trained and experienced provider in an effort to get you to choose an poorly educated, minimal trained, inexperienced (“experts” in normal and therefore incapable of preventing, diagnosing and managing complications) lay person like themselves.

Obstetricians are not saints and there is plenty wrong with the current organization of medicine, but don’t be fooled. Homebirth midwives, doulas, childbirth educators and purveyors of NCB and homebirth books and websites aren’t interested in you and don’t even care whether your baby lives or dies (since “babies die in the hospital, too”). There is NO ONE more committed to making sure that you and your baby are healthy than your obstetrician.

A new study to be published in the April issue of Obstetrics and Gynecology demonstrates that in the wake of a uterine rupture, providers have no more than 18 minutes to deliver the baby before the baby experiences significant hypoxia, and only 30 minutes until the baby suffers major neurological impairment.

The paper, entitled Uterine Rupture With Attempted Vaginal Birth After Cesarean Delivery: Decision-to-Delivery Time and Neonatal Outcome by Calla Holmgren et al. was undertaken to provide the most accurate information possible about the conditions needed to make attempted vaginal birth after cesarean (VBAC) as safe as possible.

The authors note:

The increasing rate of primary and repeat cesarean delivery in the United States is of concern to physicians and patients, and vaginal birth after cesarean delivery is considered to be one way to lower the overall cesarean delivery rate. Trial of labor after cesarean delivery (TOLAC), which peaked at 31% in 1998, has decreased progressively since (8.5% by 2006), primarily because of issues surrounding uterine rupture. Although rupture of the uterus during TOLAC is rare, it can be devastating for both the mother and neonate when it occurs, and it is a major liability risk for physicians. The American College of Obstetricians and Gynecologists’ guidelines advise physicians that TOLAC is most safely undertaken in hospitals where staff can immediately carry out an emergency cesarean delivery. This view is based on the premise that the ability to rapidly intervene will minimize adverse neonatal outcomes. However, immediate availability is loosely defined, and it is not clear how rapidly the fetus must be delivered after uterine rupture to prevent neonatal death or neurologic sequelae. The purpose of this study was to examine whether an association exists between neonatal outcomes and the time from diagnosis of uterine rupture to delivery of the neonate.

In other words, should hospitals refuse a trial of labor to women with a previous C-section if they cannot guarantee that both an obstetrician and and anesthesiologist are on site to start a C-section with less than a half hour?

What did they look for?

The primary adverse outcome was defined as an abnormal umbilical pH level less than 7.0 or a 5-minute Apgar score of 7 or less. Secondary adverse outcomes included fetal or early neonatal death and neonatal neurologic injury attributed to uterine rupture. Neonatal neurologic injury was defined as otherwise unexplained seizures, clinically obvious cerebral palsy, or developmental delay attributable to hypoxia resulting from the uterine rupture.

Who was included in the study?

Within the 10 hospitals studied, 40,772 women were identified with a prior cesarean delivery between January 1, 2000, through December 31, 2009. Of these, 11,195 women (27.5%) attempted TOLAC, with successful vaginal delivery for 9,419 (84.1%) patients… In total, there were 36 cases of documented uterine rupture (0.32%) during TOLAC.

What did they find?

Of the 36 patients, 13 (36.1%) met our criteria for a primary adverse outcome of umbilical artery pH level less than 7.0 or 5-minute Apgar score less than 7. These patients were compared with the 23 patients without this outcome. Median (range) time to delivery for the primary adverse outcome group (n=13) was 19 (9–40) minutes compared with 14 (0 –38) for the nonadverse outcome group. Results after stratifying the sample by hospital type yield a similar result, with those experiencing the primary outcome having, on average, a 5.5-minute (95% confidence interval [CI] 0.0 –15.0) longer time to delivery than those who did not experience the outcome…

Seventeen neonates (47.2%) were delivered less than 18 minutes after identification of uterine rupture. Of these, two neonates had an abnormal 5-minute Apgar score, but both of these neonates had an umbilical pH level greater than 7.0 and none had neurologic injury. Eighteen patients were delivered more than 18 minutes after suspicion of uterine rupture (50.0%). Of these, 11 met criteria for a primary adverse outcome and three met criteria for an adverse secondary outcome. One patient did not have suspected uterine rupture during labor.

Seventeen neonates (47.2%) were delivered less than 18 minutes after identification of uterine rupture. Of these, two neonates had an abnormal 5-minute Apgar score, but both of these neonates had an umbilical pH level greater than 7.0 and none had neurologic injury. Eighteen patients were delivered more than 18 minutes after suspicion of uterine rupture (50.0%). Of these, 11 met criteria for a primary adverse outcome and three met criteria for an adverse secondary outcome. One patient did not have suspected uterine rupture during labor.

A chart of the data makes the relationship between time to delivery and risk of adverse outcomes quite clear.

More than 83% of babies delivered more than 30 minutes after uterine rupture experienced major neurological complications.

As the authors explain:

Our study focused on serious neurologic morbidity in cases of confirmed uterine rupture during TOLAC. In 36 cases of acute uterine rupture, there were no fetal or neonatal deaths. Delivery within less than 18 minutes was associated with adverse primary outcome in two cases, but this was based on a 5-minute Apgar score less than 7; both neonates had normal umbilical pH levels. Three neonates in our study sustained long-term neurologic damage. These neonates were delivered 31, 40, and 42 minutes after uterine rupture was suspected on clinical grounds. When uterine rupture was identified in a timely fashion and delivery occurred in less than 30 minutes, there was no long-term neonatal morbidity in our study. However, delivery within 30 minutes did not prevent every case of low umbilical cord pH level or low 5-minute Apgar score, so these results should be interpreted with caution…

The authors conclude:

Uterine rupture during TOLAC is a rare but serious complication that requires prompt recognition and delivery of the fetus. The response time necessary to prevent neonatal injury has been uncertain and controversial. In our study, all neonates delivered within 18 minutes from decision to delivery had normal umbilical cord pH levels. Delivery within 30 minutes was associated with good long-term outcomes…

This is an important study that has the potential for wide impact. The study strongly confirms the ACOG recommendation that babies should be delivered as soon as possible in the wake of a uterine rupture. Intervals longer than 18 minutes resulted in demonstrable hypoxia and intervals longer than 30 minutes resulted in major neurological impairment. Studies like these make it extremely unlikely that hospitals and malpractice insurers will liberalize access to VBAC.

Dear Massachusetts Legislators,

I have heard that you are considering licensing homebirth midwives who have the CPM (certified professional midwife) designation. Before you reach a decision, there are 8 important facts that you ought to know about homebirth and CPMs.

1. ALL the existing scientific evidence, as well as state and national statistics show that homebirth with a homebirth midwife dramatically increases the risk of neonatal death. The most recent CDC statistics for PLANNED homebirth with a non-nurse midwife has a death rate 7 TIMES HIGHER than comparable risk hospital birth.

How about individual states with licensed homebirth midwives? Colorado statistics on planned homebirth show an appalling death rate double that of all births (including high risk and premature births), California has a mortality rate double that of low risk births, and over the past 10 years planned homebirth in Oregon has had a death rate at least 3 times higher than comparable risk hospital birth.

2. The studies that claim to show that homebirth is safe are examples of bait and switch. The widely quoted Johnson and Daviss study (BMJ 2005) compared planned homebirth in 2000 with hospital births in papers dating back to 1969. Comparing planned homebirth in 2000 with low risk hospital birth in 2000 (the data was available) shows a death rate 3 times higher for homebirth.

Moreover the authors do not disclose that Johnson was the former Director of Research for the Midwives Alliance of North America, and Daviss, his wife, is a homebirth midwife. They do disclose that the study was funded by a homebirth advocacy foundation.

3. There are two types of midwives in the US, certified nurse midwives and certified professional midwives. Certified nurse midwives are real midwives with education and training that exceeds all other midwives in the world. In contrast, certified professional midwives (CPMs) are not real midwives at all. The “credential” was made up by women who would not or could not complete real midwifery training. CPMs lack the education and training required of midwives in ALL other first world countries. The CPM is not recognized and is not eligible for licensure in ANY other first world country.

4. Most women who have the CPM designation haven’t attended midwifery school of any kind. They have completed a program of unmonitored “self-study” and paid the fee.

5. The “thought leaders” of homebirth are a self-proclaimed midwife who has no midwifery training (Ina May Gaskin) and who let one of her own children die at homebirth, a self-proclaimed “expert in obstetric research” (Henci Goer) who has no training in obstetrics or research, and a washed up talk show host (Ricki Lake).

6. According to the WHO, the best measure of obstetric care is PERINATAL mortality, and according to the WHO, the US has one of the lowest rates of perinatal mortality in the world.

7. The Midwives Alliance of North America, MANA, the organization that represents homebirth midwives, spent the years 2001-2008 collecting data on the outcomes of planned homebirths. During that time they publicly proclaimed that they would release the data to show that planned homebirth is safe. Once the data was analyzed, they changed their mind. MANA REFUSES to release the death rates for the 24,000 planned homebirths in their database. It doesn’t take a rocket scientist to figure out that MANA’s OWN DATA shows that homebirth increases the risk of neonatal death and they are hiding it so that American women will not find out.

8. Two out of three babies who died at homebirth would be saved in the hospital. Zero babies who die in the hospital would be saved at homebirth.

Homebirth leads to preventable neonatal deaths. All the existing scientific evidence confirms this and all the available state and national statistics demonstrate this. Even MANA knows that homebirth leads to preventable neonatal deaths; they just don’t want the Massachusetts legislature and American women to find out.

Sincerely,
Amy Tuteur, MD

Homebirth midwife Charlotte Russell, CPM explains how and why homebirth midwives provide bad care.

Russell herself claims she does not follow many of these self-justifications for bad care, but she gives us great insight into what many homebirth midwives do.

The central motivating factor for homebirth midwives providing bad care? Protecting themselves from accountability. For homebirth midwives, it’s all about what’s good for homebirth midwives.

1. Russell is startlingly honest about homebirth transfers:

… Do you think that when you need to transport to a hospital for the safety of you and your baby, I’m going to be eager to call an ambulance and explain what is going on, then follow the ambulance to the hospital and talk to the physician who is on the receiving end of your care and share my name and charts and record of your prenatal care and labor with him so that you have continuity of care? No. I am going to try to find a way to keep you from the hospital. I may keep you home longer than I should and possibly, although I like to think not, longer than is safe. And when it becomes clear that you need to go (and probably needed to go an hour or two ago), I am going to worry about what may happen when we do go…

Instead of thinking about you and your care and your baby, I am going to be thinking about my own four babies, whose mother might be in jail when they wake up in the morning. When given the choice between going to jail for providing you a homebirth and being present to mother my kids, the children are a higher priority.

2. Practicing without a license (this does apply to Russell): some state midwifery boards such as Louisiana, can’t be counted on to dismiss the charges as the midwifery board of Texas will reliably do.

… In Texas, as a licensed midwife, there are rules in place for complaints against midwives to be reviewed by a committee comprised of two licensed midwives, a physician, and a member of the public. This means that consumers and physicians who have a valid complaint regarding their care have recourse. It also means that a midwife who has a complaint filed against her for anything but a valid reason can trust that the committee will treat her fairly with regard to that complaint.

In Louisiana, there is no such process. Out of five Louisiana licensed midwives I have known personally, two had their licensed suspended THE VERY WEEK a physician called with a complaint. Investigation of the complaint began after the suspension of the midwife’s license, which left clients without a midwife to attend them and left her without the ability to contribute to her family financially. In the third case I am aware of, a complaint was initiated and the midwife hired an attorney before her license was suspended. Although the midwife was technically able to continue practicing, she did not continue to practice in Louisiana and the investigation of the complaint took months.

3. Rejection of standards of practice and accountability:

… If you read the laws and rules carefully, a midwifery client is required to see an obstetrician twice in her pregnancy. This obstetrician is required to verify that the client is low risk and agree to be her back-up physician, meaning that this doctor will receive her transport should she need to transport to the hospital…

Russell sees a conundrum:

The fundamental problem I see with the way the laws and rules are written is that midwives are not trusted to determine risk and refer when something risky presents itself. Therefore if the fundamental problem is that midwives aren’t trusted, Louisiana midwives as a group must prove themselves trustworthy in order to have any hope of changing the laws and rules to allow us to be the primary care providers to pregnant women, as is the case in other states. Now, how can I say to the board and the legislature that midwives as a whole are trustworthy and will not “sneak” in high risk women, if I–or any other midwife, for that matter–am breaking the law and practicing in an illegal and “sneaky” way?

She’s right. It’s difficult to prove that you are trustworthy when you have no intention of keeping your word, following rules and transferring patients in a timely fashion.

The ultimate irony? They have a name for this approach to providing care. It’s called defensive medicine. The midwife’s medical decisions are based on what will protect her, not what is good for the patient.

So the same people who claim that hospitals are unsafe because doctors practice defensive medicine by doing everything possible to prevent bad outcomes for the patient and her baby, are cheerfully providing their own brand of defensive medicine, although in their case they are willing to allow bad outcomes for the patients and babies as long as it prevents bad outcomes for homebirth midwives themselves.

Presumably, in the name of journalistic balance, The Atlantic just published a new piece asserted the same old natural childbirth lies.

First, on March 15, 2012, The Atlantic published The Case for Hospital Births by Tufts obstetrician Adam Wolfberg. Using the story of Laura and her failed homebirth as a framing device, Wolfberg explained why obstetricians dread homebirth transfers. As could have been predicted, homebirth advocates responded with their typical combination of ignorance, petulance and anger.

Yesterday, The Atlantic, attempted to present an opposing view. No, they didn’t ask another obstetrician who also has experience with homebirth transfers. They didn’t ask an obstetrician at all. Instead, they published a piece of pure inanity by a professor of bioethics, Alice Dreger, under the absurd headline The Most Scientific Birth Is Often the Least Technological Birth.

It is a wholesale regurgitation of the natural childbirth community’s canard du jour that “obstetricians ignore the scientific evidence.” It is filled with the typical NCB combination of inane assertions and outright lies, as well as a brand new sanctimommy slogan that unmedicated childbirth is “sexy.”

Inane assertion #1:

… [I]f I wanted to scientifically maximize safety, I should give birth pretty much like my great-grandmothers would have …

Sure. Awesome idea. Oh, wait, wasn’t neonatal mortality 10 X HIGHER then? Wasn’t maternal mortality 100 X higher then? Oops!

Inane assertion #2:

… [W]hen the evidence still supports a low-interventionist type of pregnancy and birth management for low-risk cases, we’ve made virtually no inroads to making birth more scientific in the United States.

What scientific evidence would that be? Prof. Dreger doesn’t say. But she proudly announces that she “consulted” the scientific literature, when what she really means is that she read a few Cochrane Childbirth Reviews and thought that was the scientific literature. Apparently she didn’t consult the rest of the scientific literature including the paper on the Cochrane Childbirth Reviews, which shows that most are riddled with serious errors of statistical analysis that render their conclusions suspect or even useless.

Inane assertion #3:

Our midwife could be trusted to be scientific, whereas our obstetrician could not.

Now that’s funny. 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 are assiduously scouring the scientific literature, reading the main obstetric journals each month, and changing their practice based on the latest scientific evidence.

I have the greatest respect for certified nurse midwives, but the concept that they are “scientific” whereas obstetricians are not is simply laughable.

Prof. Dreger disseminate the typical NCB drivel:

but I can’t count how many women have said to me that they “chose” pain medication during birth even though they were never told the risks of pain medication

What are those “risks”? She doesn’t say. Where are the consent forms that fail to inform women of the potential side effects of epidurals? She doesn’t offer any.

… [R]outine ultrasounds [do] not leave babies safer

Who said they did? No one. But how about ultrasounds to provide missing information or address a mother’s right to terminate a pregnancy if the fetus has a major structural anomaly or genetic defect? Prof. Dreger doesn’t say.

To learn more about the use or misuse of technology, Prof. Dreger doesn’t consult obstetricians. No, she asks a sociologist who has “compared birth in the US to birth in The Netherlands.” Dreger clearly has no idea that The Netherlands has one of the highest perinatal mortality rates in Europe and where midwife attended low risks births (home or hospital) have HIGHER perinatal mortality than high risk births attended by Dutch obstetricians.

It’s hardly surprising that Prof. Dreger’s article is filled with mistruths, half truths and total falsehoods. She wrote an entire article about the state of obstetric practice without consulting a single obstetrician.

Dreger finishes with a flourish that would make any sanctimommy proud. She offers the opinion of her doula:

“Birthing a baby requires the same relinquishing of control as does sex — abandoning oneself to the overwhelming sensation and doing so in a protective and supportive environment.” If only more women knew how sexy a scientific birth can be.

Sorry, Prof. Dreger, your choices don’t mark you as sexy, regardless of how much you’d like to think so. They mark you as a typical natural childbirth advocate, uneducated about obstetrics, science and statistics, and remarkably gullible.

With apologies to Hans Christian Andersen:

Early in this century there lived a Mother who was so exceedingly fond of feeling superior to other mothers that she was constantly searching for ways to distinguish herself from them. She claimed to be the best, most natural, most authentic mother in the world. She took no interest in current events, did not work, and only socialized with other mothers in order to boast of her superior birth, breastfeeding, parenting style.

Now one fine day a swindler, calling herself Midwife, arrived. She declared that she could facilitate the most magnificent birth that one could imagine; better than a homebirth, better than an unassisted birth … an orgasmic birth! Not only was the birth perfect in every way – unassisted, in water, videotaped and painless – but it culminated in the greatest orgasm ever. Even better the orgasm had the special power of being invisible to everyone who was not a super awesome, all natural, authentic woman.

“What a splendid idea,” thought the Mother. “If I had such a birth I could prove that I was the best mother ever, much better than those C-section, formula feeding, unattached mothers.”

So the next time the Mother got pregnant, she gave the swindler Midwife large sums of money to pay for the Midwife’s books and videos and the two week course at her Farm. Day after day the Midwife went home with more money.

Now the Mother was eager to know give birth and have a giant orgasm. She was, however, somewhat uneasy. “Suppose,” she thought secretly, “suppose I don’t have an orgasm at the exact moment of birth. That would mean I am not an awesome, all natural, authentic woman. That cannot be,” she thought, but all the same I will watch videos of orgasmic birth. “I will best be able to see how a birth orgasm looks. After all, I am the best mother and most authentic woman possible.”

So the Mother and her best friend downloaded videos of orgasmic birth from YouTube and watched them together with the Midwife.

The best friend opened her eyes wide. “Shit!” she thought. “I see only women in pain, screaming their heads off at the moment of birth.” But she did not say so.

The swindler Midwife begged the best friend to come nearer and asked her how she liked the videos. “Are not the births painless, and see how rapturous is the orgasm,” she said. The best friend stared and stared. She saw nothing of the kind because there was nothing of the kind. But she did not dare to say she saw no orgasm. “Nobody must find out,”‘ thought she. “I must never confess that I could not see it.”

Instead the best friend said:

“Oh, it is beautiful – most excellent, to be sure. Such a painless birth, such rapturous orgasm. I am now a believer in Orgasmic Birth.” To the Mother the best friend said, “That birth was truly orgasmic.”

Two and a half weeks after her due date, the Mother started having contractions and was looking forward to experiencing painless labor. Accompanied by the Midwife, a doula, the best friend, her college roommate, her husband and her preschool age children, the mother labored in the kiddie pool in her living room. After 4 hours of contractions, painful and getting more painful, the mother was only dilated to 2 centimeters.

“Is not the labor painless?” said the swindler Midwife. “Notice the pleasurable ‘waves’, the glorious ‘tightenings’.” The doula, best friend, the college roommate and the husband looked at the Midwife and nodded. Each thought that the other could see that the labor was painless and pleasurable.

“What can this mean?” said the Mother to herself. “This is terrible. Am I so unnatural? Am I not authentic? This is disastrous,” she thought. But aloud she said, “Oh, the labor is painless and the ‘tightenings’ are wonderful.” She would not, she could not, admit that the contractions were painful, when her doula, her best friend, her college roommate and her husband were watching. “Magnificent.” “Excellent.” “Exquisite,” went from mouth to mouth and everyone was pleased.

Everyone sat up all that night waiting for the labor to progress. By 8 AM, the Mother was entering transition, vomiting into the kiddie pool and screaming with every contraction.

The Midwife issued inspiring statements. “You are doing great,” she said. “You are having a painless labor,” she said. “Let’s tweet your birth progress to your Twitter list. Oh, and could you move a little to the left so that you are not obscuring the videographer’s view of me.”

“Magnificent,” cried the doula, the friend, the roommate and the husband, even as the Mother retched and grunted. Nothing would have persuaded them to admit they were watching a labor that was far from painless, for fear they would be thought unnatural or inauthentic.

And so the moment of birth approached. The doula, the best friend, the college roommate and the husband cheered and cried, “Oh, how painless is the labor. How soothing the waters of the kiddie pool.” No one dared to admit that mother appeared to be in agony and was screaming for the pain to stop.

“Soon it will be time for my orgasm,” the mother thought to herself in scattered moments of rationality.

Finally the baby was crowning and the Mother was screaming, “Get it out of me. Get it out of me now!”

The head was born and then … nothing. “Surely I will split apart in agony,” the mother thought.

The swindler Midwife paled. “Push!” she screamed. “Your baby is stuck!”

“Fuck,” she was heard to mutter under her breath, “another shoulder dystocia.”

The Midwife twisted the baby this way and that. The doula, the best friend and the roommate were screaming, “Push!” and the preschool age children were crying hysterically. The husband was dialing 911.

With an ear splitting howl, the mother pushed with all her might. The baby emerged limp and blue into the hands of the Midwife. It’s right arm dangled at a unnatural angle. The mother fell back into the kiddie pool hemorrhaging into the dirty water.

“Don’t cut the cord,” screamed the Midwife. The doula tried to perform CPR. The best friend burst into tears. The college roommate ran to open the door for the ambulance crew. The husband was heard pleading, “Breathe, baby, please breathe.”

The EMTs bagged the baby who was still unconscious and wrapped him carefully preparing for transport to the hospital.

“Wait,” shouted the Midwife, “there hasn’t been any skin to skin contact. She needs to nurse that baby first!” The EMTs ignored the Midwife and barreled through the door, with the husband grabbing his car keys to follow.

Several hours later, the profoundly anemic Mother was finally settled into bed after passing out several times. The husband had called from the hospital. The baby had regained consciousness and was now intubated and doing well. His arm still dangled limply at his side.

“You pushed out a 10 pound baby with no help at all,” crowed the Midwife, “and you had an orgasm, too.” The doula, the best friend, and the roommate nodded.

From the doorway a little child suddenly gasped out, “But, Mama,” he said,” it looked like it really hurt.”

The Midwife, the doula, the best friend, and the roommate stared at the child. Her little boy’s words seemed to rouse the Mother from her near stuporous state. “What can this mean?” said the Mother to herself. “I did not have an orgasm. I was in agony. Am I so unnatural? Am I not authentic? This is disastrous,” she thought. The Mother made up her mind.

“Oh, no, honey,” she managed to whisper, “I enjoyed it. I had an orgasm.”

She drew herself up and smiled proudly, and the doula, the best friend, the college roommate and the Midwife nodded enthusiastically.

The swindler Midwife collected her multi-thousand dollar fee and headed for the door. “Sorry to run,” she called over her shoulder,” but I’ve got to help the videographer with the footage. A little judicious editing, and we’ll have yet another orgasmic birth video. Check for it on YouTube tonight.”

This piece first appeared in April 2010.

The most important thing every women needs to know about the philosophy of natural childbirth is that it romanticizes birth. It romanticizes birth in the same way that countless generations of men have romanticized war. And it does so using similar language and for similar reasons.

General Sherman said, “War is hell.” It’s an accurate description, so it’s surprising that very few people said it before the 19th Century. War is about maiming, gutting, killing other human beings. and potentially being killed oneself. It is horrifying in every possible way, yet that is not how it has traditionally been portrayed. Young men were (and in some places still are) taught that war is about courage and honor, that it is the highest pursuit of “real” men and that success in battle is the ultimate achievement.

For most women, childbirth is hell, replete with agonizing pain, blood and bodily fluids. Traditionally it has been portrayed as excruciating, life threatening and a punishment administered to women by God. But in the mid 20th Century, natural childbirth advocates decided to romanticize it. They romanticize the pain by minimizing it, attaching spiritual significance to it, or by claiming that it is “good” for mothers and babies. They romanticize the dangers by pretending they don’t exist, and they romanticize the death toll by ignoring it altogether. Natural childbirth advocates go so far as to appropriate the classic exhortations of war mongers. Indeed, they refer to women as “birth warriors.”

What’s the worst thing that a man can be in society that values war? A coward. There is nothing worse than refusing to fight, particularly if it is because of the fear of being killed. Cowards are vilified in societies that value prowess in war and brave men receive medals. Natural childbirth advocates have appropriated the same reasoning, even if they express it slightly differently. What’s the worst thing that a pregnant woman can be in a subculture that romanticizes birth? Someone who does not “trust” birth, but “fears” it, i.e. a coward. Natural childbirth advocates teach women that birth is about courage and honor, that it is the highest pursuit of “real” women and that “success” in birth is the ultimate achievement.

The natural childbirth literature is filled with claims about the pernicious nature of fear in childbirth. It is considered the ultimate put down of doctors, who supposedly have created a “culture of fear” around birth. Fearing pain, and abolishing it with pain relief is derided as the province of weak women who are unwilling to fulfill their true function in life. Being alert for complications is asserted to cause complications. Most importantly, just as men who fear war are shamed with the appellation ‘coward,’ women who do not subscribe to the romantic idealization of birth asserted by NCB advocates are also shamed. They are portrayed not merely as cowardly, which is bad enough, but as bad mothers who care more about themselves than the well being of their babies.

Why did generations of men romanticize war? They did so for a very simple reason, to get other men to follow them into battle. Who would want to go to war if they knew what it was really like. Why do natural childbirth advocates romanticize birth? To get other women to validate them by following them and mirroring their choices.

The most important thing that every women needs to know about the philosophy of natural childbirth is that it bears as much relationship to childbirth as army recruiting posters bear to the reality of war. Both are all about hiding the grim and painful reality because very few people would willingly choose either war or natural childbirth if they knew the truth.

Emily’s story as told by her mother Jenn:

Here’s what you really need to know about my daughter’s delivery: After nearly 4 hours of pushing, a senior nurse noticed a disturbing pattern on the monitor tracing. (A junior nurse missed it – as it likely would have been listening via stethoscope, since for the longest time the heart rate recovered – it just lost variability and also recovered increasingly slowly.) Unfortunately at that point the OB was in surgery. 10 minutes later her heart stopped. 5 minutes after that, she was born flat. She was resuscitated and put on a ventilator. The cause was pretty clear, particularly after pathology reports on the placenta, cord, and my daughter: the cord was around her neck twice, and very short between her and the placenta. The labour itself cut off the supply of oxygen from the placenta to my daughter.

We talk about risk-taking in labour but I don’t think people understand the risks they are taking. Some of us know. So here’s what I can share with you.

When my daughter was born vaginally, she was grey. They lifted her limp body over me and my first sight of her — so much for that breast crawl! — was more like a rubber doll. The room had burst into action when the code was called: There were about 15 people in the room and the anesthesiologist was primarily working on her. All I could see were their backs, hear them ripping into sterile packs and talk to each other. I was in shock for a number of reasons and my mind really couldn’t process what was going on. (This is one reason I am sometimes skeptical of natural birth stories where babies have had adverse outcomes. You could have told me just about anything and I’m not sure my logical mind would have been skeptical.)

They worked for probably 45 minutes or an hour. I have no memory of delivering the placenta, or the fundal massage that is on my charts, although I do remember the nurse showing me the sections of the cord that had been cut (three pieces, to get it off her neck and the baby out, I think); it was white, which the nurse remarked on. The OB stitched the tear I had and the epidural was removed, but I have no memory of that either. My focus was on my baby. I waited and waited for a cry that obviously never came, but that was all I could think of: When will she cry?

When they moved her to the NICU my husband took a couple of looks between her and me and then I told him to go with her and he did, relieved that I let him follow his instincts. He became a father in that moment; I could see it in him. This is what happens when your child has a birth accident: You’re not a single biological unit, and suddenly this is the kind of choice you are making. Who goes with the baby? Who goes with the mother?

When I first saw my daughter after delivery, she was in a NICU. The staff asked me not to touch her because they were concerned about the stimulation. I noticed that her chin was trembling and I asked the staff if she was cold. The nurse gently explained to me that what I was seeing was a seizure. She was on painkillers and anti-seizure meds and other things to stabilize her sodium levels etc. These are common results of this kind of injury.

I asked what the prognosis was. The neonatalogist told me that a good outcome would be “learning difficulties.” I heard this as learning disabilities and my mind — which races, by the way, planning a whole life in an hour while you’re lying there without your child in your arms — started to plan out tutors for reading. What the doctor meant, incidentally, was — sorry to use what has been a terrible slur, but the way I grew up this is the term that has meaning — retarded. Probably the diagnosis would have been CP, but I really don’t know.

I got a few hours of sleep thanks to a drug — bring it on, at that point — and when I woke up my daughter’s condition had worsened. As the brain struggles with hypoxia (and other organs by the way: kidneys, liver, heart), my very lay understanding is that it swells. The swelling causes more issues, like seizures, and can cause more damage. Our hospital had made the decision to transfer my daughter to one of the best children’s hospitals in the world, about 40 minutes away. I wanted to see her but they say they had to stabilize her for transfer and no one would be allowed in during that time.

So the next time I saw my daughter she was in a massive portable incubator that also dispenses medication, monitors vitals and does all kinds of things I guess. It looked like one of those sleeping tubes in Alien. The neonatologist from the big hospital had taken a Polaroid of my daughter for me to hold, with the NICU information on the back and reassurance that I could call any time of day or night for updates on my daughter’s condition. Then she sat on my bed and took my hand and told me that I should start to get my mind around the idea that my daughter’s condition was very, very grave.

I started to get it, around the edges of 9 months of hope and expectation. A little bit. Then they left for the new hospital, with my husband. By now my family had arrived and talked around me, but inside I was starting to plan a new life: where to build a wheelchair ramp. Running through our savings in my head. Deciding I would quit my career. I had worked in social services years before and I started to think about relief care, home support, physical therapy. My husband and I had joked we never wanted to have a minivan. I had a close friend with a severely disabled son who had recently received a totally tricked-out van for wheelchairs and I started thinking about that. These are the things you think about. This is what your life becomes, turning on a dime.

After I was discharged from the hospital my husband came to get me. We walked out alone. We had brought the baby car seat up into the L&D room — why we thought we had to have it right there I don’t know, along with our playlists for labour, nursing pillow, cute outfit and multiple cameras — and we carried it out empty and put it in the trunk, where it sat for 5 months, despite repeated trips. Trust me, I will never forget that walk out with no baby.

We stopped for clothes at the house – I was really tired and torn and sore and bleeding and should have had a shower, but I couldn’t wait five more minutes, all of a sudden, to get down to see my baby. I got walked through the handwashing and entry protocols for the NICU. My daughter was in a sea of machinery, lots of it beeping and hissing — the soundtrack of any NICU’s parent’s experience. It was a wash of relief to see her again; there is a deep pain at all that separation.

Which got worse.

That evening was the first time I got to hold my daughter. The nurses were so kind; it took three people to manage all the tubes and hookups just to lift her out and into my arms. Regardless of everything else, holding your baby for the first time is amazing. There is no feeling like it in the world. This is one of the things you put into danger when you take unnecessary risks.

From there the news went downhill pretty quickly. We had to wait 48 hours after the initial injury to get accurate scans. I walked into the room when the technician was doing an EEG which measures electrical activity in the brain.

He was crying.

Other scans, including a MRI, followed. By that afternoon the whole team gathered to give us the news: My daughter had suffered extensive brain damage (and other, but they focused on the brain). She had no pupil reflexes for light. She had no swallow reflexes. She could not move her arms and legs. She could not hear. She would never speak, see, laugh, roll over. The damage was deep down into the parts of the brain that are the most primitive. The staff was caring but direct. They described for her what the quality of her life would be.

What about neuroplasticity? We asked with our fancy-pants New York Times reading vocabulary. (So “educated.”) The brain is not able to recover when most of it has died, said the neonatalogist. Brain cells don’t regrow. (8 years later and stem cell research progresses, but it’s not that far yet.)

The other news, he said, was that she was learning to breathe on her own. Amazing, her little fighting body. Except…and everyone in the room waited for him to take his breath to take this one…he didn’t think this was necessarily a positive thing. He explained that no one could predict what would happen exactly if we took her off the supportive measures, but the longer we waited the more likely she was to survive, and if she was able to breathe on her own we would have a lot of complicated decisions to make down the road, including withholding nutrition. He did not recommend that we wait.

I’m not a scientist, but I am a trained observer of people. I watched this man tell us this. He believed it. He sorrowed for it. He was not distant or distracted. He was giving us, I believe, his absolute best from his years – he is very prominent – of experience. The nurses too. The technicians as well. In that room there were probably 50 years combined experience of watching children and infants with brain and other injuries.

My husband, who had been more aware and more present with our daughter as she was transferred and so on, and I had talked about this possibility the night before…the long dark night before. We had spent quite some time in quiet prayer and thought about it and we had gone over whether we were just afraid to raise a disabled child or not. (We were not. You don’t have to believe me but – we weren’t. She was our daughter.) We did, however, not want her to suffer if there was no chance of any kind of minute quality of life. So we already knew what our answer would be, but after the staff made sure we didn’t have more questions they gave us some time. We took about 45 minutes to let the information sink in and to be sure. To turn that possibility over into our present reality. Our daughter was basically brain-dead. It’s your nightmare scenario, as a parent.

We decided to take her off life support that evening. (For what it is worth, I don’t think we could have withheld feeding. For us it was one thing if she couldn’t breathe without machines; another to do the opposite of what basically every parent throughout time has done: Feed their kids.)) We wanted to get as much family down as possible, and we wanted to plan a baptism. So we did. I decided not to be in the room when they actually took the tubes out. Looking back I’m not quite sure what I was scared of – maybe that I would not be able to go through with it. So the nursing team did that and then they brought her out. All she had was an IV to keep her comfortable – hydrated and with painkillers.

It was the first time we held her properly. We passed her around to her grandparents and aunt after the nurses showed us how not to cut off her breathing. She had stridor; she was working for those breaths with a high pitched sound I will never forget. She lived through the baptism. She laid in my arms. She laid in my husband’s arms. Everyone else went home. We stayed the night with her. We changed her diaper. Slowly…slowly…slowly…over 16 hours, in fact, she stopped breathing. We couldn’t tell she was breathing for the last hour or so and the resident came three times before calling it. She had died. Not passed, not born asleep. She died.

Afterwards, her nurse and we bathed her. We made molds of her hands and feet. We dressed her (for her autopsy). We said goodbye. We walked out of a second hospital without our daughter – and without our hope. We had decided to call her Emily Hope before she was born, and so she was, but hope, as it turned out, was not enough.

A few days later we dressed her again for her funeral. We had about 200 people show up. Once we were past 32 weeks we had pulled out the stops. This baby was hotly anticipated by our wide clan of family, friends and colleagues. We had two dressers full of gifts. We had renovated our house to make it more baby-friendly. After the second trimester passed I spent days and days and days planning everything positive. We had struggled through miscarriages and other issues. I didn’t let a smidgeon of soft cheese or a bite of sushi past my lips; I didn’t dye my hair; I had a cold with no drugs, miserable for a week. I swam and walked and did everything right. In labour I was high on anticipation to meet this child.

It never crossed my mind – so much for positive thinking! – that she could be dying and birth attendants not quite realize it. I thought we were crossing the finish line. I didn’t know how subtle the early signs are, or how twisted thinking can get when the goal is to not do something that should, in fact, be done. I wasn’t aware these things still happen to families. (Once they do, the stories come out though.)

This is the reality of oxygen. I cannot tell you what our lives would have been like with just slightly better results – would she still be alive? Would she have choked to death one night when one of us didn’t wake up to suction her? Would she be in a home after our deaths? Or what our understanding would have been if it had been slightly worse, if she had been stillborn and we had not had the time with her that we had to cope and understand and see her as a living baby and ask pointed questions.

But I can tell you what it would have been like with a c-section, because since then I have gone on to have two healthy children. It would have been great. I might have thought wow, she looks healthy, how unnecessary was that? Cords are around the neck all the time! It’s no big deal! I might be on a forum upset about a scar right now.

But my medical team didn’t catch it or make conservative decisions in my baby’s favour.

And this is what happened. This is her story and mine.

Let’s get the arguing out of the way here: Yes, my baby died in hospital. However, she did not die due to a cascade of interventions. She died due to a negligent cascade of non-intervention. We essentially had the level of care I would have had at home: One birth attendant making decisions based on her philosophy of natural childbirth. As I was pushing I cannot tell you how many times she said to me “trust your body!” “You’re a woman, we’re strong!” “You were made to do this.”

My hospital was aiming for natural birth ideals (particularly low-c-section rates). When you aim for an ideal statistic rather than a case-by-case assessment, sometimes I think — combined with other factors — this is where you end up. But bluntly, it also took a lot of screwing up. Don’t think a single midwife is immune, where nurses & an overworked OB were not.

As for “not simply meant to live.” She WAS meant to live. You should have seen the fight in that little girl. Have a close look at her picture, when she was the healthiest and pinkest; the least scarred; when she still had hair (they had to shave it for needles and tests). You tell me that baby girl was not made to live.

She had an accident, like a car wreck or getting caught on blind cords or choking on a hot dog. These are all accidents which, as parents, we take measures to avoid. 99.9999% of the time, hospital staff would have caught this one. Her umbilical cord got pinched off during a vaginal delivery. There was nothing mystical about it. There was no way to control it. No amount of positive thinking would have helped. Nothing at home could have helped.

Had the proper interventions taken place, she would be running around just after her 8th birthday.

This isn’t about painkillers. It’s not about accomplishment. It’s about responsible, appropriate, knowledgeable decision-making in birth choices and during labour. This is what risk is really about.