Far be it from me to complain about the participation of trolls in the comment sections of this blog. Trolls serve a very valuable function here. They drive conversation, illustrate various deficiencies in the thinking of NCB and homebirth advocates, and provide endless entertainment.

Every science based website with a comment section has trolls, and they share several important characteristics.

1. Trolls invariably have essentially no education on the topic under discussion. Whether it is anti-vax trolls who have no knowledge of immunology, creationism trolls who have no understanding of evolution, or NCB and homebirth advocacy trolls who lack basic education in science, statistics and obstetrics, trolls literally have no idea what they are talking about.

2. Despite profound and crippling ignorance, trolls generally believe that they are knowledgeable. This is a result of the Dunning-Kreuger effect. As Dunning and Kreuger wrote in their original paper, Unskilled and Unaware of It: How Difficulties in Recognizing One’s Own Incompetence Lead to Inflated Self-Assessments:

We propose that those with limited knowledge in a domain suffer a dual burden: Not only do they reach mistaken conclusions and make regrettable errors, but their incompetence robs them of the ability to realize it.

3. Trolls have a serious problem with scientific evidence; they don’t understand what it is. Contrary to what trolls believe, websites written for lay people are not a source of scientific evidence, long lists of citations copied for those websites are not scientific evidence, and the mere existence of a paper that expresses a particular point of view is not scientific evidence.

4. Trolls seem to be entirely unaware that you have to READ a scientific paper (the whole paper, not just the abstract) before you can declare that it is scientific evidence that supports your point of view. They are also unaware that publication in a peer review journal does not mean that a paper’s conclusions are scientific evidence, merely that the author’s views are worth being included in an ongoing discussion of an issue.

5. Trolls have terrible problems will logical fallacies. They love and frequently employ the fallacy of the lonely fact, the argument from ignorance, and the ad hoc fallacy.

6. Trolls have serious problems with basic logic.

7. Trolls suffer from hubristic self-assessment. Sure it takes a real doctor 4 years of college, four years of medical school and 3-5 years of residency to become knowledgeable about his or her field, but the troll assumes that is for mere mortals. For a troll, reading a bunch of websites written for laypeople is all that is necessary to achieve a level of expertise high enough to advise and criticize professionals.

8. Trolls love conspiracy theories.

9. Trolls are convinced that they are “brilliant heretics.”

10. Trolls are easily frustrated when others fail to recognize their blinding (to themselves) brilliance. In very short order, they start personally insulting those who frustrate them by demanding scientific evidence that they cannot provide.

11. Trolls inevitably flounce. As Skeptico advises in his hilarious Handbook of Woo:

Finally, when you’ve used up all the above tactics, say you’re not going to waste any more time with the [critics] you’ve been debating because they’re too sad, stupid, closed-minded, ______ (insert other flaw the [critic] has) to understand your brilliant arguments. Make a big grandiose statement and exit to start anew somewhere else.

The homebirth statistics keep on coming and they keep demonstrating the same thing: homebirth increases the risk of death.

I’ve written extensively about the appalling rate of perinatal death at the hands of licensed midwives in Colorado, and, of course, the overall US statistics show that homebirth with a direct entry midwife triples the neonatal death rate. The latest data comes from Missouri and the trend continues. Homebirth has a risk of intrapartum death that is more up to 20 times higher than hospital birth.

Birth outcomes of planned home births in Missouri: a population-based study by Chang and Macones published in the American Journal of Perinatology in August 2011 is notable for careful methodology.

… We obtained data from the Missouri live birth and fetal death files that have been linked together by the Missouri Department of Health and Senior Services… The Missouri vital record system is considered very reliable and has been adopted as a “gold standard” to validate other vital statistic datasets in the United States…

Our study sample consisted of women who delivered singleton pregnancies between 36-44 weeks of gestation … Pregnancies complicated by major fetal anomalies and breech presentation were excluded …

The authors divided the more than 800,000 births by place of birth and attendant creating three groups: hospital/birth center births attended by physicians and CNMs, homebirths attended by physicians and CNMs and homebirths attended by non-CNM midwives. (Of note, unplanned homebirths and births attended by non-midwives were excluded.) The groups differed significantly by maternal characteristics.

Women who had planned home deliveries attended by either non-CNMs or physicians/CNMs were more likely to be older, to be white, to have more children, to be overweight and to deliver at greater than 41 weeks gestational age, but less likely to be a Medicaid recipient or unmarried, to smoke during pregnancy, or to have a maternal medical risk factor.

Despite this, the outcomes in the homebirth groups (both those managed by non-CNMs and those managed by physicians or CNMs) had much poorer outcomes.

… [W]e observed that rates of newborn seizures were 4 per 1000 births among planned home births attended by non-CNMs, 0.6/1000 among planned home births delivered by physicians/CNMs and 1.1 per 1000 births among deliveries made by physicians/CNMs in hospitals and birthing centers. The rates of intrapartum fetal death were 0.9 per 1000 births among planned homebirths attended by non-CNMs, 1.7/1000 among planned home births delivered by physicians/CNMs, and 0.1 per thousand among deliveries made by physicians/CNMs in hospitals or birthing centers.

Rates of neonatal death were 1.4/1000 among planned homebirths attended by non-CNMs, 0 among planned homebirths attended by physicians/CNMs and 0.6/1000 among hospital/birth center births attended by physicians CNMs. This difference does not reach statistical significance, however.

After the authors employed multivariable logistic regression models:

… We observed that planned home births attended by non-CNMs remained positively associated with odds of newborn seizures after controlling for confounders. Specifically, the adjusted OR of newborn seizure among births delivered by non-CNMs was more than 5 times as much as the odds in hospital/birthing center births delivered by physicians/CNMs … For intrapartum fetal death, planned home births attended by non-CNMs and physicians/CNM yielded adjusted ORs of 11.24 and 20.33 respectively relative to hospital/birthing center births attended by physicians/CNMs …

The authors conclude:

Our analysis demonstrates cause of concern about safety of planned home births attended by non-CNMs and physician/CNMs. The results of our study suggest that planned home births are associated with increased likelihood of intrapartum fetal death and newborn seizures, despite the fact that the lowest risk women choose this birthing option.

As is the case with most homebirth studies, this study could not separate out home birth transfers from the hospital birth group. Therefore, the study likely underestimates the magnitude of the increase risk posed by homebirth.

The state of South Australia, which includes the city of Adelaide, has published it’s perinatal mortality rates. The data shows that planned homebirth has a perinatal mortality rate more than 17X higher than comparable risk hospital birth.

The report, Pregnancy Outcome in South Australia 2009, is a dry recitation of birth statistics without editorial comment. The statistics are analyzed in every possible way to give a vivid picture of birth in the state. Among the ways the data is analyzed is according to place of birth and the results are surprising and distressing.

Any way you look at it, planned homebirth has a dramatically higher rate of death. The stillbirth rate is higher; the neonatal mortality rate is higher; and therefore, the perinatal mortality rate is higher. In fact, the perinatal mortality rate is more than 17 times higher than that at comparable risk hospital birth! These findings are even worse than the appalling findings from Western Australia, where the data showed that homebirth tripled the rate of perinatal death.

Surprisingly, the perinatal death rate at birth centers was also far higher than the rate at comparable risk hospital birth. Birth centers had a perinatal mortality rate 5X comparable risk hospital birth. This is completely unexpected. Birth centers should have a perinatal mortality rate lower than hospital birth because women with preexisting medical conditions and serious pregnancy complications are concentrated in the hospital group.

Since there were only a relatively small number of planned homebirths, the exact magnitude of the risk is probably smaller than 17 fold. However, the increased risk of perinatal and neonatal death is a remarkably robust finding, extending across time periods and countries and states. To my knowledge, all the existing international, national and state statistics show that homebirth increases the perinatal and neonatal death rates by at least a factor of 3. There is only one exception, a single paper out of Canada; the paper is notable for very strict homebirth criteria and a high transfer rate of greater than 20% in the homebirth group.

There is really no question that homebirth increases the risk of perinatal death. The only people who appear to be unaware of this are homebirth advocates themselves.

The utter contempt with which homebirth midwives greet attempts to hold them accountable for homebirth deaths and disasters is truly amazing. Consider Melissa Cheyney and company enshrining into Oregon law the ability to practice homebirth midwifery without regulation of any kind including a license, Amy Medwin in North Carolina soliciting funds from her midwifery colleagues to pay the fines stemming from her felony guilty plea, or Lisa Barrett who is so contemptuous of the law as to tweet from the courtroom during her Coroner’s Inquest. But for sheer nerve, you can’t beat the midwives who been stripped of their licenses and continue practicing homebirth midwifery.

Case in point: Kaleem Joy (aka Jody Lyn Robinson, aka Jody Lyn Brecke) of One Heart Midwifery in Citrus Heights, California.

Kaleem/Jody is cool as you please in advertising her illegal midwifery practice on her own professionally designed website.

Midwifery for me is a joy. To enlighten woman to their power and strength and to support them in giving birth to their babies safely and satisfyingly at home… It is especially important to me that babies be respected and honored in their ability to be born and celebrated. I am there to watch over safety, this I know. But I expect the best and the best happens. We use medical equipment when needed. I use my tools of the trade i.e.: homeopathy, herbs, cranial sacral therapy, awakening a woman to the truth about birth and it’s power and purpose, nutrition, education and my optimisms. Trust is really the key.

Kaleem/Jody boasts about her midwifery license and RN, as well as her myriad of “degrees” in quackery:

… Very simply I have been a pediatric RN, Licensed midwife, and am now a Certified Professional Midwife, Massage Therapist specializing in Cranial Sacral Therapy of newborns, infants and pregnant woman. I have a Certificate degree in homeopathy that I graduated with honors and have self studied herbs for over 20 years.

In her CV, she boldly proclaims:

RN 1983-2005 …
Licensed Midwife of State of California 1997– 2003 …

She does not mention that the midwifery license, and subsequently the RN, were stripped from her for gross negligence:

… [O]n and between January 10, 2000 and January 12, 2000, Respondent committed acts constituting gross negligence for patient M.I.’s labor and delivery … Respondent admitted the truth of the charge … resulting in the surrender of her Midwife Certificate No. LM-63.

Subsequently Kaleem/Joy’s RN was revoked. The revocation was initially stayed, pending satisfactory completion of a 3 year probation. She failed to meet the probation requirements and was stripped of her RN.

The loss of her midwifery license means that Kaleem/Joy is no longer entitled to practice midwifery in Califoria, but that hasn’t stopped her from attending births and publicly advertising her services. And the best part? Kaleem/Joy teaches midwifery students.

The midwifery students are practicing on roasts using sutures and instruments with sterile fields and yes even head lamps. We cut a hole out to simulate a yoni and asked them to do interrupted, basting, and figure 8s. The week before we did knot tying with instruments and yarn…

… Sisterhood among students and midwives and among the midwifery community as a whole, is the heart of the midwifery.

Homebirth midwives like Kaleem/Jody should be prosecuted for practicing midwifery without a license. It is nothing short of appalling that a homebirth midwife commits gross negligence, loses license and continues practicing homebirth midwifery and publicly advertising that illegal practice.

Homebirth midwives abhor being held accountable for letting babies die preventable deaths. When they’ve exhausted their typical gambits: the “baby would have died anyway” gambit, the “some babies just die” gambit, and the “mother is responsible for the baby’s death” gambit, they move on to what they consider the ultimate threat.

That would be the “ignore the dead babies, or other babies will die” gambit.

It’s what Mark Twiggs, lawyer for the indefensible Lisa Barrett, is employing in a last desperate attempt to sway the coroner’s court as well as the court of public opinion.

According to today’s piece on an Australian TV channel:

Greater regulation of home births would force women determined to avoid a hospital birth to go “underground”, increasing the risks for mother and child, an inquest has heard…

In final submissions on Friday, counsel for Ms Barrett, Mark Twiggs said mothers who chose to have a home birth should not be considered uneducated or naive.

He said such women had considered the risks and were determined to avoid delivering in hospital.

“They have studied and made a choice, and they should always have that free choice,” he said.

Mr Twiggs said more regulation surrounding home births would take away that choice.

“They need help, but heavy regulation is going to push these people underground,” he said.

In other words, Twiggs warns that if the Coroner’s Court doesn’t let Lisa Barrett get away with murder, other midwives might refuse to participate in future avoidable homebirth deaths and then what would happen? Homebirth advocates might resort to homebirths without a midwife and OTHER BABIES COULD DIE!!! Simply put, if the Coroner’s Court doesn’t allow Lisa Barrett to kill babies, mothers might do it themselves.

This threat (for it is a blatant threat) is absurd on a variety of levels. First, it is a false empirical claim; indeed, it is really two empirical claims, neither one of which is proven.

The first empirical claim is that punishing homebirth midwives for preventable neonatal deaths will have no deterrent effect because those same women would had homebirths anyway and their babies would have died anyway. That could be true, but there’s no evidence that it is true. Moreover, it conveniently ignores the enabling role played by the midwife herself. When a midwife like Lisa Barrett ensures the mother that homebirth in her situation is safe, she encourages that homebirth. It is equally if not more likely that a homebirth midwife, by telling a mother that the risk of the baby’s death is so great that she won’t get involved, will lead the mother to conclude that hospital birth is the safest option for her baby.

The second empirical claim is implied: homebirth midwives are preventing more deaths than they cause. Sure these babies died at Lisa Barrett’s hands, but she must have saved some babies who would have died otherwise. In other words, yes, homebirth midwives kill babies, but they save even more babies. There’s no evidence that is true, either. Where’s the data that shows that neonatal deaths at homebirth have dropped since allowing midwives to attend homebirth? There isn’t any and there isn’t likely to be any. That’s because babies die at home for lack of emergency C-section facilities and for lack of expert neonatal resuscitation. Parents cannot provide these, but homebirth midwives can’t provide them, either. Homebirth midwives could theoretically be saving lives, but there’s certainly no evidence that they do, and certainly no evidence that they save more lives than they lose.

Leaving aside the fact that it is based on unproven claims and assumptions, the threat is remarkably cold blooded. It’s essentially a hostage claim: yes, we killed these babies, but you shouldn’t punish us because if we’re not allowed to let hostages die, then less professional hostage takers (parents) will take over and even more hostages will die.

Twiggs is accurately representing Barrett in this threat. She expresses no remorse for the preventable deaths of these babies. She refuses to take any responsibility for these deaths. Indeed, by all appearances, she doesn’t especially care that they are dead. But she knows that the judges care. So she threatens that if she is not allowed to get off for letting these babies die, even more babies will die. But this is not a seminar in utilitarian theory. We don’t accept the death a few babies just to prevent the entirely theoretical deaths of a few more.

Tate Spencer-Koch and Jahli Jean Hobbs died utterly senseless, totally preventable deaths because Lisa Barrett didn’t know what she was doing and didn’t care, either. She is responsible for those deaths and she should be held accountable for those deaths. No less an authority than the Australian Supreme Court deemed that Barrett could not avoid being investigated by insisting that the babies were dead when they were actually alive.

The coroner’s inquest that Barrett feared has demonstrated that she, in her hubris and ignorance, is responsible for those deaths. The Coroner’s Court should hold Barret accountable for these deaths and should not be swayed by her last, desperate gambit, the claim she should be allowed to let babies die or else mothers will do it themselves.

Remember the Flintstones?

Flintstones, meet the Flintstones
They’re the modern stone age family
From the town of Bedrock
They’re a page right out of history

Let’s ride with the family down the street
By the courtesy of Fred’s two feet …

The conceit of the Flintstones animated series is that prehistoric life faithfully emulated modern life except machines used rocks, animals and people power in place of motors. Hence Fred drove a car, but made it move using his feet. Wilma vacuumed the floor using a mammoth’s trunk (connected to a live mammoth).

Melissa Cheyney and the homebirth midwives of Oregon have set out to create the Flintstones version of midwifery. How else to explain Auscultated Acceleration Testing?

First a little background. I have written many times about fetal monitoring and how intermittent auscultation provides only a fraction of the amount of information of an electronic fetal monitor. For example, intermittent auscultation is incapable of parsing the most ominous fetal heart rate tracing.

In addition, intermittent auscultation cannot be used to verify the well being of the baby through a non-stress test (NST). Not until now that is, since Melissa Cheyney recently came up with the Flintstones version of an NST!

A non-stress test, as its name implies, evaluates the baby in the absence of pitocin induced contractions. NSTs are graded reactive or non-reactive. In a reactive NST, the fetal heart rate accelerates for at least 15 beats per minute (bpm) above the baseline for at least 15 seconds, at least twice in a twenty minute period. The NST is the gold standard for determining fetal well being. A reactive NST is almost a sure sign of a healthy baby.

Here’s an image of a reactive NST. You can see that the baseline fetal heart rate is 150 bpm and there are two accelerations up to 180 bpm, each lasting approximately 40 seconds.

Not surprisingly, it is impossible to perform an NST using intermittent auscultation, which is a problem for homebirth midwives since it is the gold standard for assessing fetal well being. But wait! What would the Flintstones do? The Flintstones would jury rig a set up that appeared to be able to perform the same function using only the tools available to them, but could never actually work in reality.

Melissa Cheyney and colleagues have brazenly (and with a straight face) proposed the Flintstones alternative to an NST. It is called Auscultated Acceleration Testing. Not surprisingly, it requires tools that are easily accessible to a homebirth midwife such as a fetoscope and a watch with a second hand.

Here’s how is “works”:

Step 1 – Listen to fetal heart rate (FHR) for 2 minutes to establish a baseline rate.

Step 2 – To do this, count the FHR in every other 5-second increment and record on an AAT collection graph.

Step 3 – If an acceleration of 2 beats per 5-second period does not occur during the initial 2 minutes, then perform an external manual manipulation of the fetus using a 5-second external stimulation 3
procedure.

Step 4- If no fetal movement occurs in the 2 minutes following the initial shaking procedure, repeat steps 1, 2 and 3.

Step 5 – Continue collecting data for an additional 2 min. and end at 6 minutes.

It’s difficult to imagine anything more moronic. First of all, using a regular watch means that there is no way to know if it is keeping time correctly. This is especially critical considering that the “test” involves measuring heart beats in 5 second increments and multiplying by 12 to obtain the heart rate. Even the tiniest error in timekeeping is going to be magnified by a factor of 12, rendering any results meaningless.

Second, the extremely small time increment means that any error made by the time keeper is also multiplied by a factor of 12. Consider that the normal fetal heart rate is anywhere from 120-160 bpm. In a 5 second increment, that would be 10 – 13.3 beats per increment. It is literally impossible to get an accurate reading of the fetal heart rate by listening to a 5 second increment.

Even if it were possible to get accurate, meaningful information from this exercise (and it is not), it does not even meet the criteria for a reactive NST, which translated into 5 second increments would be a sustained increase lasting at least three 5 second increments.

So this is a test done with an inaccurate timekeeping device by an inaccurate time keeper (since it is literally impossible to get an accurate reading of fetal heart rate in a 5 second increment) that doesn’t even provide the information needed to satisfy the criteria for a reactive NST. It is to an electronically monitored NST what Wilma using a mammoth trunk is to vacuuming. It provides a bizarre cartoon appearance of an NST that can’t possibly work in the real world.

From where did Wilma Flintstone Melissa Cheyney dredge up this bit of idiocy?

According to the protocol, it comes from Paine, et al. A comparison of two time intervals for the ausculated acceleration test, (2001) Journal of Midwifery and Women;s Health. The paper begins:

Midwives around the world often work with minimal resources because technology is not available to their populations. In locations where electronic fetal monitoring (EFM) is available, the nonstress test (NST) is currently the most widely used technology for screening fetuses at risk for antepartum fetal death or other poor perinatal outcomes. In other settings, low-technology methods such as fetal heart rate auscultation or maternal fetal movement counting may offer the only means of antepartum assessment available to midwives. Interest in an inexpensive, easy-to-use antenatal screening test lead to the development of the auscultated acceleration test (AAT) in the late 1980s. Using a fetoscope, midwives or nurses can easily administer this test, which is conducted without the use of EFM.

In other words, this test can be used as a middling to poor substitute for an NST in developing countries where there is no access to electronic fetal monitoring. It is NOT in any way a substitute for a real NST, which, as we already know, is the gold standard.

(Just as an aside, this paper cited in support of the accuracy of the auscultation test is grossly underpowered to measure anything and therefore, is meaningless).

Let’s review:

1. Melissa Cheyney and the Board of Direct Entry Midwifery have implicitly acknowledged that the NST is the gold standard for assessing fetal well being.

2. Homebirth midwives have no access to the technology. (That, of course, means that they have no business taking care of women, but that’s another matter altogether).

3. Therefore, they’ve come up with the Flintstones equivalent of an NST, a test that was literally designed to be used in places that have little more than stone age technology.

4. This Flintstones equivalent, just like the mammoth vacuum looks like an NST, but just as the mammoth vacuum doesn’t clean the floor, the auscultation acceleration test literally cannot produce any meaningful results. That’s because the measuring instrument (a watch) is not calibrated for accuracy; the time keeper listening in a 5 second increment is literally incapable of accurately calculating the fetal heart rate, and the test has never been shown to work in any case.

Exactly how stupid does Melissa Cheyney think the women of Oregon are? How stupid does she think the legislators of Oregon are?

This is not a “test.” This is yet another pathetic effort to convince everyone that no education and no technology are required to ensure fetal health at the hands of birth junkie hobbyists who can’t be bothered to get a real midwifery degree and simply proclaim themselves “midwives.” It is an attempt to fool the public and fool the regulators into letting these self proclaimed midwives make money despite their ignorance, regardless of how many babies are harmed or die in the process.

For those who believe that this is anything other than a brazen, self serving attempt to protect hobbyist “midwives” at the expense of babies lives, I’d like to sell you a mammoth vacuum cleaner that you’ll just love.

Ten:

One to teach the course “Empower yourself by changing your own light bulb.”

One to whisper affirmations encouraging the light bulb to be in the correct position.

One to photograph the event.

One to tweet the event live.

One to fill the kiddie pool. (Note: professional electricians claim that standing in water while changing a light bulb is dangerous, but they just say that to ruin your light bulb changing experience.)

One to call 911 if you get electrocuted while standing in water while changing the light bulb.

One to reassure you that people get electrocuted changing light bulbs even when they are not standing in water, so you shouldn’t let the warnings of those stupid electricians scare you.

One help you eat while changing the light bulb in order to keep up your strength.

One to tell you to turn the bulb only when you get the urge.

And finally, one to actually change the light bulb and pretend to have an orgasm while doing it.

This post first appeared in April 2010.

I read this story, and all I could think of was the Disney Superbowl commercials where the announcer asks the winning quarterback what he’s going to do next, and the quarterback says he’s going to Disney World.

Announcer: Hey, Mrs. Bernstein, your baby was just left profoundly brain injured by your decision to have a homebirth. What are you going to do next?

Mrs. Berstein: I’m going to refuse to vaccinate him!

There are two possible responses to precipitating a death or disaster because of homebirth nonsense: those with a modicum of critical thinking skills ask themselves whether, perhaps, since their beliefs about homebirth turned out to be entirely wrong, their other pseudoscience beliefs might also be wrong. But for those for whom pseudoscience is akin to religious beliefs, and where critical thinking skills are never applied, they just keep believing … and keep putting their innocent child at risk of death because of their own stupidity.

Consider this new thread on Mothering.com, Needing help with my backbone please, in the vaccination forum. mrsbernstein writes:

Due to circumstances that I would change in a heartbeat if I could, my son had severe hypoxia during birth (and subsequent brain injuries). He is currently “delayed” and is almost 10 weeks old…

Our original plan was the Select/Delay. And managed to find a Ped that was/is VERY willing to go along with this AS LONG AS we do the TDap on “schedule.” And my dear babe is “scheduled” to get the Vax on Monday.

Along with the “medical” route of handling my son’s brain trauma, we are also seeking alternative routines of care. One being with our family Chiro who is ADAMANT that we don’t start ANY vaxes until age 2 … and maybe not even then…

I’m so torn as what to do… My gut is saying “NO”. But my mind and family are justifying JUST THIS ONE.

So let’s see if I get this straight, Mrs. Bernstein. Your gut told you to have a homebirth and it left your baby profoundly brain damaged. Now your gut is telling you avoid vaccination and you think you should listen to it??!!

You’ve already hurt your child very badly through your personal beliefs. Here’s a suggestion: please consider that your “gut” is worse than useless, and start educating your brain. And by education, I do not mean researching things on Mothering.com a virtual cesspool of idiotic beliefs and scientific ignorance.

It is IMPOSSIBLE to make an educated decision about vaccination without an education in immunology. You can either choose to listen to someone who does know and understand immunology (a pediatrician) or you can choose among a plethora of charlatans, like chiropractors and homebirth midwives, whose ignorance will hurt and perhaps kill innocent children.

Mrs. Bernstein, you have already made one hideous mistake. Please learn from it:

Your “gut” is not trustworthy. Your MDC friends are not knowledgeable. Your use of alternative practitioners is deadly, and your child has already been profoundly injured by your well meaning ignorance.

You have screwed up in the worst possible way, but you probably didn’t understand that pseudoscience is dangerous. Now you know that it can maim and kill; don’t screw up again.

You’re thinking about homebirth and you are interviewing the midwife. Or perhaps you’ve already decide on a homebirth, but you have developed a complication and you need to decided whether to deliver in a hospital instead. Maybe you’ve decided on a homebirth, but you haven’t decided whether to have the tests routinely included in MD supervised prenatal care.

You’ve asked the midwife for her opinion, but before you decided to accept it, you need to ask yourself a critical question: What’s in it for the midwife?

For better or for worse, most obstetricians have no vested interest in how you end up with a healthy baby. Most obstetricians make no extra money for a C-section, and they certainly don’t profit from fetal monitoring, routine prenatal tests, ultrasound, induction, just about any intervention you can think of. Homebirth and NCB advocates routinely deride “defensive medicine” but even that it about giving you a healthy baby. They order tests and recommend interventions because they think it will increase the chances of an excellent outcome, not because it will line their pockets.

The situation is entirely different for a homebirth midwife. She stands to make money if she can convince you that you need nothing more than what she knows how to provide. She stands to lose money if she can’t provide what you need. Therefore, it is important to understand that an inherent financial conflict of interest exists for a homebirth midwife at every juncture requiring a decision.

Are you a good candidate for homebirth?

For homebirth midwives, this is the threshold financial issue. Unless they can convince you that it is safe for you to give birth at home, they can’t make any money from you. Therefore, they have a tremendous financial incentive to minimize any and all risk factors. Previous C-section? Previous shoulder dystocia? High risk condition in pregnancy? In any of these cases, you are not a good candidate for homebirth. If your homebirth midwife tells you that you are, ask yourself: what’s in it for her?

Following her financial interest will lead her to tell you that you are a good candidate even when you are not. A midwife who is not distracted by her own financial concerns will tell you honestly that you are at greater risk of a poor outcome. She may offer to attend you anyway, to facilitate whatever choice you make, but if she denies you are at increased risk, you should be asking yourself whether she is worried about her wallet instead of being appropriately concerned about you.

Should you be tested for gestational diabetes?

This one is a no brainer. The primary treatment for gestational diabetes is diet. Any pregnant woman contemplating homebirth is almost certainly very careful about her diet, eating only what she believes is best for her baby. Learning that she needs to cut down on sugar to keep her baby safe is valuable information and it is easy to act on it.

There may be a downside for a homebirth midwife, though. She may not have access to the equipment needed for the screening test or the follow up test if the screening test shows a problem. Or a diagnosis of moderate to severe gestational diabetes might risk you out of a homebirth, depriving her of income. There’s a lot of potential downside to a homebirth midwife in following the recommendation to screen for gestational diabetes. Therefore, if your midwife tells you it’s okay to skip the test, consider that it benefits her, but it does not benefit you and it certainly does not benefit your baby who may be exposed to excess blood sugar for weeks or even months.

You are measuring unusually large or small for dates. Should you have an ultrasound?

If the issue turns out to be as simple as an error in your due date, both you and the midwife will benefit from having the information. However, if there is a problem like intra-uterine growth retardation or if it turns out you are carrying twins, you are no longer a good candidate for homebirth. If your midwife tells you that it’s not an issue if you are consistently measuring smaller or larger than dates, she is thinking of herself, not of you. If you have the information an ultrasound will provide, you might decide to change your provider. That’s a financial loss for her.

Should you be tested for group B strep?

Group B strep is the leading infectious threat to newborn babies. Since routine screening and IV antibiotics in labor for women who are found to be GBS has been instituted, the neonatal death rate from GBS has dropped 70%.

For most homebirth midwives, though, GBS testing is all downside. They may not have access to the screening test. They may not have access to IV antibiotics. They may not know how to put in an IV. It is ever so much more covenient for a homebirth midwife to ignore GBS than to acknowledge the danger. If a homebirth midwife recommends not testing for GBS or if she recommends something other than IV antiobitics for treatment, she is making a decision that benefits her and puts your baby at risk. It is not in her interest to be honest about GBS, so you have to think long and hard about whether to take her recommendation to avoid screening and/or conventional treatment.

You are 41 weeks. Should you have a non-stress test and a biophysical profile (ultrasound)?

Does your midwife have easy access to that technology? If not, and she tells you that you don’t need to check the well being of your postdates baby, you need to ask yourself why. Is it truly because the tests are unnecessary, or is it because she can’t arrange them for you or she doesn’t want to have you risked out of her care if the NST or biophysical profile are abnormal?

You are 42 weeks? Should you have an induction?

Whether you decide to have an induction or not, you should know that going beyond 42 weeks doubles your baby’s risk of death (and that’s in the hospital; it’s almost certainly much higher at home). Your midwife cannot perform an induction and thereby loses control of your care. She has financial and personal benefits to denying the increased risk of postdates and denying the benefit of induction. If she tells you to avoid induction for postdates, you need to ask yourself whether she’s doing so because of what’s in it for her, or because it is truly the best course for you.

Should you transfer in labor?

There’s thick meconium. Or there’s an unusual amount of bleeding. Of labor is going far more slowly than normal. Should you transfer to the hospital? You’ve probably paid the midwife by now, so there’s no financial incentive for her but there is an even more powerful motivation at work. If you transfer to the hospital, she may end up in legal trouble. It is far better for her to convince you to stay home than to let you transfer to a hospital. When she begs you to trust birth, ask yourself: is that for your benefit and the safey of your baby or is it to protect herself?

The financial incentives for homebirth midwives are almost always in opposition to what is safest for you and your baby. For a homebirth midwife, ignorance is bliss (and cash). It is better for her not to know about complications, better for her not to test for high risk conditions, better for her not to treat problems that she doesn’t have the equipment or experience to treat and better for her not to transfer to the hospital. But all too often, it is not beneficial or even safe for you and your baby.

Homebirth midwives want to convince you that you never need more than what they can provide. They have a vested interest in denying the validity of tests they cannot order, monitoring they cannot offer, and treatments they cannot access. The next time your homebirth midwife recommends ignoring conventional medical practice, ask yourself: what’s in it for her?

The homebirth midwife trusted birth and the baby suffered permanent brain damage. It appears, however, that this homebirth midwife carried insurance. Although it does not change the fact that their child is disabled, it allowed the parents to sue and obtain a large settlement that will be used to care for their son.

According to the American Association for Justice website:

Ara Flores delivered her first child at home with the assistance of Gale Aucott, a certified nurse midwife. Aucott monitored Flores’s baby using a stethoscope and fetal doppler. After pushing for almost three hours, Flores gave birth to a son. He was born with Apgar scores of two at one minute and four at five minutes. Now 5, he suffers from permanent brain damage, seizures, and other problems.

Flores and her husband sued Aucott’s employer, alleging Aucott failed to recognize and properly respond to fetal distress and failed to transfer Flores to the nearest hospital after she had been pushing for two hours. Among other claims, the plaintiffs asserted that Aucott should have monitored the baby every 10 minutes instead of every 45 minutes.

The lawyer’s website reports:

Plaintiffs’ experts maintained that the Defendant mid-wife failed to appreciate a prolonged second stage of labor and that the mother needed to be transferred the nearest hospital once her second stage of labor approached 2 hours. Long second stages of labor are associated with increased fetal and maternal morbidity and mortality because fetal reserves may become low from the stress of prolonged labor and pushing. Plaintiffs maintained that long second stages of labor may be indicative of impending problems and the Defendant mid-wife failed to appreciate or react to the length of the second stage which was at minimum 2 hours and 47 minutes.

The midwife did attempt to defend herself.

The multiple defense experts opined that the second stage of labor was not too long and did not necessitate that she be transferred to the nearest hospital. A neuro-radiologist expert for the defense also maintained that the child’s neurological insult occurred several days before the birth.

But her most creative attempt at defending herself is more than a bit ironic:

Finally, the defendant’s obstetrical expert testified that because the home birth did not include the use of electronic fetal monitoring it was impossible to know whether the baby was in a hostile intra-uterine environment and required an emergency cesarean section.

There you have it, folks. A homebirth midwife declared that she did not know that the baby was suffering from a lack of oxygen during labor because it is impossible to tell with only intermittent auscultation. If you really want to know if a baby is in distress, you have to use electronic fetal monitoring.