Let’s do a little thought experiment. Instead of evaluating the claims of homebirth midwives through the prism of ideology, let’s assess each claim by asking whether or not homebirth midwives profit. I’m going to go out on a limb here, and repeat a prediction that has been made by regular commentors on this blog: homebirth midwifery recommendations are driven by whether they impact midwives’ ability to make money.

1. Pain is empowering and pain relief is unnecessary.

This is probably the central therapeutic recommendation of homebirth midwifery, and (surprise!) it has a tremendous impact on the ability of homebirth midwives to make money. Simply put, homebirth midwives can’t make any money from women who want pain relief. Therefore, considerably energy is spent trying to convince women that they don’t need and shouldn’t have pain relief. That involves a variety of false assertions:

childbirth isn’t really painful
childbirth is actually pleasurable (orgasmic birth!)
childbirth pain is empowering
relieving childbirth pain is harmful to the baby
relieving childbirth pain increases the risk of C-section

Pretty clever when you think about it; they cover all the bases: childbirth isn’t painful; it is painful but the pain is good for you; and it is painful but relieving the pain is bad for you. This is the threshold issue for homebirth midwives; if they can’t convince you that pain relief is unnecessary or harmful, they can’t make money from you.

2. Electronic fetal monitoring is unnecessary

Yet another amazing coincidence! Homebirth midwives can’t provide EFM so it is critical to convince women that it is unnecessary or, better yet, harmful: it restricts women and slows labor; it leads to “unnecessareans”; it doesn’t improve outcomes. It doesn’t matter whether those claims are true; all that matters is convincing potential fee paying patients that they are true.

3. Birth is inherently safe.

The entire rationale for hospital birth is the incontrovertible fact that childbirth is inherently dangerous. Without liberal use of the technology and interventions of modern obstetrics, an appalling number of mothers and babies will die in childbirth. Who’s going to pay thousands of dollars to be attended by a layperson whose primary qualification is that she is a “birth-junkie” if that means taking on an increased risk of death? Almost no one.

Therefore, it is critical to pretend that childbirth is inherently safe and to hide the mounting evidence that homebirth with an American homebirth midwife kills babies who didn’t have to die. That’s why MANA (the Midwives Alliance of North America) is strenuously attempting to hide their death rates from the American public.

4. There’s no reason to prophylactically treat group B strep, or (an equally efficacious lie) group B strep can be prophylactically treated with (surprise!) stuff you can buy in the store like garlic (?) or antibacterial soap.

Most homebirth midwives don’t have access to IV antibiotics, the ONLY effective treatment for group B strep. If they intend to get any money from women who are group B strep positive they must convince them that IV antibiotics aren’t necessary or can be replaced by things from the local grocery store.

5. Rh- women don’t need Rhogam.

Most homebirth midwives don’t have access to Rhogam or getting access to Rhogam would require them to interface with real medical professionals and expose their illegal status. In acknowledging the need for prenatal Rhogam, homebirth midwives risk loss of money and legal action. Far better to lie about the need for Rhogam.

This brief list merely scratches the surface. I’m sure if we put our heads together we can compile a far longer list. The list will contain a variety of heterogenous and even contradictory claims, but every element will be united by one common theme. For homebirth midwives; if you can’t make money from it, you must convince women that it is unnecessary or even harmful.

I recently satirized one of the inane papers published by Dr. Michael Klein. Klein has heavily publicized his papers in the mainstream press and on natural childbirth blogs like Lamaze’s Science and Sensibility. The conclusion that drew the most press attention was Klein’s claim that women who seek care from obstetricians are undereducated about childbirth decisions.

The study was ludicrous on its face because it never actually assessed women’s knowledge of the risks and benefits of various childbirth interventions. It only assessed women’s self-perceptions of their level of education. In other words, Dr. Klein never showed that women who seek the care of midwives know more about childbirth interventions, only that women who seek the care of midwives THINK they know more about childbirth interventions.

The study is sloppy and lazy; sloppy because it did not control for when in pregnancy the self-assessments were made. It assume that women who felt that they didn’t know much about childbirth interventions during the first trimester would feel the same way in the third trimester. It is lazy because Klein didn’t bother to do the difficult work involved in assessing what each woman knew; he took the lazy way out and relied on each woman’s personal assessment of her knowledge.

Klein, a family practice physician, has in the past worked in conjunction with the Society of Obstetricians and Gynecologists of Canada (SOGC) in efforts to lower the C-section rate and increase the rate of breech deliveries in Canada. Yet in a nearly unprecedented move, the SOGC has issued a position paper condemning Klein personally for his shoddy and irresponsible conclusions.

The Society of Obstetricians and Gynecologists of Canada is concerned that the conclusions highlighted in the UBC media release issued on 13 June 2011, regarding a trio of studies, has oversimplified the issues related to the use of technology in childbirth. While the SOGC has be a strong proponent for normal childbirth and the reduction of C-sections rates in the country, the issues related to decision-making in obstetrics is far more complex than the conclusions drawn by Dr. Michael Klein.

As Dr. Ahmed Essat, president of the SOGC points out:

It is inappropriate to draw conclusions based on attitude alone. The decision making process during labor and delivery is far more complex than that.

The SOGC objects to Klein’s underlying assumption that technology is bad, pointing out that:

Society, including the new generation of health-care professionals (not only obstetrician-gynecologists), favor the use of technology.

Dr. Andre Lalonde, executive vice president of the SOGC, rejects Klein’s studies and his claims about what they show:

The SOGC feels that comments and conclusions expressed by Dr. Michael Klein are too simplistic and do not take into account a large number of factors that affect the care of pregnant women …

I couldn’t have said it better myself.

At least several times a month, natural childbirth advocates parachute into this blog with the declaration:

“babies die in the hospital, too.”

Duh? That’s why we encourage hospital birth in the first place. Childbirth is inherently dangerous, babies die all the time in nature and hospitals save a vast proportion of those who would otherwise die. Let’s leave aside for the moment the fact that MORE (a greater proportion of) babies die at homebirth, or that the most common reason babies die in the hospital is due to prematurity, to envisage why the claim is inane on it’s face.

Consider:

Non-smokers die of lung cancer, too. Does that mean that smoking is a safe?

Of course not. Smoking INCREASES the risk of lung cancer; it doesn’t kill everyone who smokes, and it kills people who don’t smoke. That doesn’t make smoking either a smart of a responsible choice.

Or:

People wearing a seatbelt die in car crashes, too. Does that make foregoing a seatbelt safe?

Of course not. Foregoing a seatbelt INCREASES the risk of dying in a car accident; not everyone who foregoes a seatbelt dies and some people wearing a seatbelt die anyway. That doesn’t make foregoing a seatbelt a smart or responsible choice.

Or:

People who aren’t drunk get into fatal car accidents. Does that mean that drunk driving is safe?

Of course not. Drunk driving INCREASES the risk of a fatal crash; not every drunk driver has a fatal accident and drivers have fatal accidents even if they are not drunk. That doesn’t make drunk driving a smart or responsibly choice.

Similarly:

Babies die in the hospital, too. Does that make homebirth safe?

Of course not. Homebirth INCREASES the risk of perinatal death; not every homebirth baby dies and babies born in the hospital die, too. That doesn’t make homebirth a smart or a responsible choice.

Back in April Brynne Potter, CPM, in her role as a board member of NARM (North American Registry of Midwives) appeared on the Kojo Nnmadi radio show to defend Karen Carr, the midwife who pled guilty to felony charges in connection with the homebirth death of a breech baby. What Potter neglected to mention is that she was on leave from her practice for recently presiding over — you guessed it — the homebirth death of a breech baby.

In the wake of that death, Potter is giving up the practice of midwifery. A supportive article in a Charlottesville newspaper bemoaned the fact that her practice Mountain View Midwives was breaking up, while entirely neglecting to mention why, implying that Potter wanted to spend more time on her NARM duties.

Oh the one hand, I applaud Potter for her mature approach to the homebirth tragedy. It is devastating for any practitioner to lose a patient, even more so, if the practitioner questions her own culpability in that death. The patient was a primip who was wrongly thought to be vertex. She purportedly “declined” vaginal exams in labor. The breech was not discovered until it began to emerge during delivery in the bathtub. The head was trapped. By the time Potter cut an episiotomy and delivered the head, the baby was dead.

A period of reflection is quite appropriate in the wake of such a tragedy. Potter ultimately decided that she could no longer attend women at homebirths. That, too, is a mature decision, considering that she, like all certified professional midwives, is grossly unqualified to provide care to pregnant women. What is far less admirable, is her determination to continue defending the indefensible by hiding any information that would alert women to the dangers of homebirth.

In addition to hiding her role in a preventable homebirth death, Potter continues to defend MANA for hiding the death rates of the 23,000 planned homebirths in ther databse. I called into the Kojo show specifically to ask Potter why MANA (the Midwives Alliance of North America) the organization that represents homebirth midwives, and the sister organization of NARM, is hiding their death rates..

Potter tried to dodge and weave:

… So I can’t really speak to a specific about some assumption of hiding. What I would say is that MANA’s — I know MANA stands ready to meet the needs of any reporting mandate. It is a private data set in which isolated cases of death would only be isolated cases similar to this case that we’re talking about today. We wouldn’t be able to make any extrapolation of a trend to homebirth. The only place we can do that is from the CPM2000, which was a cohort study that mandated all CPMs to report in prospectively all of their data for one year. And that study was published in the British Medical Journal, and it is absolutely in line with outcomes of all other published studies around homebirth, which is…

Potter almost surely knows the MANA dataset is not private, that the cases of death are not isolated and that it is simply a lie to say that we could not use the data to make a determination of the safety of homebirth with a CPM. MANA knows that homebirth substantially increases the risk of neonatal death and they are doing everything in their power to make sure American women do not find out. Potter, by acting as a spokesperson for homebirth midwifery is complicit in hiding this important information.

Potter’s comments about the Johnson and Daviss CPM2000 (Johnson and Davis, BMJ 2005) study are also untrue, but she may not have known that at the time. Since then, I have gone to her blog and explained that the “outcomes of all other published studies” as well as state and national data show that homebirth with an American homebirth midwife dramatically increases the risk of neonatal death. Did Potter address my extensive explanation. No, of course not, she — you guess it — hid it by deleting it. Not only was she unable to defend the studies that she publicly cites as supporting homebirth safety, she found the information so compelling that she removed it so no other women could learn the truth.

Ms. Potter, if you are reading this, I have a question for you:

Presiding over as completely preventable homebirth death, you appear to be shaken to your core. You reasonably concluded that you could not continue to provide a model of care that lets babies die unnecessary deaths. You KNOW that “trusting birth” kills babies who didn’t have to die. You know that MANA is hiding the death rates of CPMs because they are afraid to tell American women the truth. You know that the published data and state and local statistics confirm that homebirth kills babies.

Don’t you feel any obligation to tell American women the truth?

Raise your hand if you know a baby who died of erythroblastosis fetalis.

Not too long ago, there would have been a lot of raised hands. Before 1968, approximately 10,000 babies died each year of erythroblastosis fetalis, also known as hemolytic disease of the newborn (HDN). Then Rhogam was introduced.

It is fashionable in homebirth midwifery circles to determine what the scientific evidence shows and then reflexively recommend the opposite. Therefore, many homebirth midwives and advocates are now suggesting that women forgo Rhogam without having any understanding of what Rhogam is, what it does, and the nature, incidence and mortality rate of the disease that it prevents.

What is hemolytic disease of the newborn (HDN) It is a relatively common condition in which a mother produces antibodies that cross the placenta and destroy the baby’s red blood cells. The baby becomes profoundly anemic, develops severe jaundice and heart failure. The mortality rate used to be approximately 50%.

Why would a mother make antibodies to her baby’s blood cells? It happens when the mother and baby’s blood type differ in an important way. Usually the difference is that the baby is Rh+ (has the RhoD antigen on its red cells) and the mother is Rh-. The baby of an Rh- mother will be Rh+ only if its father is also Rh+, but not all babies of Rh+ fathers will be Rh+.

How does the mother make antibodies against the baby’s blood if the placenta prevents the mother’s blood from mixing with the baby’s blood? The answer is there are often small leaks of fetal blood into the maternal circulation, particularly at the time of birth. They are not large enough to have any impact on the baby, but only a small amount of Rh+ fetal red cells are needed to produce an immune response in the mother.

When such a response develops, the results are often devastating to the baby, not in the current pregnancy (especially if the sensitization occurs at delivery) but in subsequent pregnancies. What happens in future pregnancies?

… [M]aternal anti-D antibodies cross the placenta into fetal circulation and attach to Rh antigen on fetal RBCs … These antibody-coated RBCs are [destroyed] by lysosomal enzymes released by macrophages and natural killer lymphocytes …

… Tissue hypoxia develops as fetal anemia becomes severe… Hydrops fetalis … starts as fetal ascites and evolves into pleural effusions and generalized edema…

… Destruction of RBCs releases heme that is converted to unconjugated bilirubin. Hyperbilirubinemia becomes apparent only in the delivered newborn because the placenta effectively metabolizes bilirubin…

This is an unmitigated disaster for the baby:

Before any interventions were available, the perinatal mortality rate was 50%. Wallerstein introduced exchange transfusion in 1945 and reduced the perinatal mortality rate to 25%. Later, Chown suggested the early delivery of those severely affected nonhydropic fetuses by 34 weeks’ gestation followed by prompt exchange transfusion helped improve survival. The introduction of intraperitoneal transfusion by William Liley in 1963 and intravascular transfusion (IVT) by Rodeck in 1981 reduced the perinatal morbidity and the mortality rate was further reduced to the current rate of 16%.

Treatment for HDN has clearly improved dramatically, but a death rate of 16% is still extraordinarily high. Imagine if you could prevent your baby from ever getting HDN in the first place, and all it took was two small injections. Since 1968, when Rhogam was introduced, there has been no need to imagine.

Rhogam is human antibody to the Rh antigen. If any fetal blood cells escape into the maternal circulation, Rhogam binds to the Rh antigen and makes it “invisible” to the mother’s immune system. One dose at 28 weeks, and another at the time of delivery is enough to prevent the mother becoming sensitized. Additional injections are given whenever there is any other chance of fetal cells leaking into the maternal circulation, such as at the time of miscarriage, ectopic pregnancy, or episodes of significant vaginal bleeding.

Rhogam has dramatically reduced the incidence of HDN. The incidence is still not zero, however, because there are other less common antigens that can also cause sensitization.

What are the side effects of Rhogam? Sometimes there is a localized skin reaction and occasionally, in people who are sensitive to blood products, there can be an allergic reaction to Rhogam itself.

So why are homebirth midwives suggesting that women refuse Rhogam? Because, as usual, they have no idea what they are talking about.

They are motivated by their insistence that nature is perfect and technology is harmful. First, they insist, bizarrely, that the no fetal blood cells will ever find their way into the maternal circulation unless “interventions” occur during birth. Ignorant of history, they are apparently unaware that HDN was first reported by a French midwife in 1609.

Ignorant of the scientific facts, as always, they are unaware of the Kleihauer-Betke test, a that allows us to quantify exactly how many fetal cells are in the maternal circulation at any given time. That’s how we KNOW that small quantities of fetal cells often slip into the maternal circulation.

Then there is their pathological fear of technology. They are absolutely sure that Rhogam might cause some damage of some kind to babies who never needed it the first place since they had a perfect placenta. They offer no scientific facts to support this claim, since there is no evidence that it is true.

What about the benefits? They don’t appear to understand that nearly 10,000 babies are saved from death by Rhogam each and every year. They have apparently forgotten, if they ever knew, about hemolytic disease of the newborn.

This is yet another example of how modern obstetrics is often stymied by its own success. A dread infant killer is easily prevented by a simple injection, so easily that homebirth midwives have no idea that the risk of death is very real and still exists.

HBAC stands for homebirth after cesarean. You often see it written with a number included, such as HBA2C, which means homebirth after 2 C-sections. In most cases, the attending midwife is violating her professional standards to supervise an attempted homebirth after multiple C-sections, but homebirth midwives think professional standards are for other people, not for them. Maybe that’s why they preside over the deaths of so many babies.

The latest completely preventable homebirth death is reported at The Guggie Daly:

Leilani had experienced two previous c-sections, with the last one being over 11 years ago…

But on June 15th, 2011, her precious son, Liam … was born still at 12:05AM. He weighed 10lbs, 5oz and was 22 inches long. He was chubby and perfect, with reddish brown hair and blue eyes like his daddy.

Leilani’s tragedy was rare and an extreme emergency whether at home or in the hospital. She had several hours of very hard labor with little progress when a severe pain across the middle of her abdomen appeared. It was extremely painful and did not go away.

The doctors verified she had experienced uterine rupture. This caused another rare emergency, a placental abruption, and this is what took Liam’s life. Her waters had broken and leaked into her abdominal cavity. It is a miracle that she is alive today. The doctors proceeded with a c-section after verifying that little Liam had passed on from this world. They had to clean out her abdominal cavity. Her uterus was shredded and the doctor spent a long time repairing it, but she will no longer be able to have biological children.

The doctors also diagnosed her with severe pre-eclampsia although she did not have that diagnosis during pregnancy, nor did she have symptoms.

Let’s see: a homebirth, 2 previous C-sections, a macrosomic baby, and undiagnosed pre-eclampsia. The perfect homebirth candidate!

And look how well it went. The uterus ruptured, the placenta tore away from the uterine wall and he baby died long before she ever got to a hospital. Way to trust birth!

As a bonus, the mother had a massive hemorrhage, extensive abdominal surgery and will be unable to bear any children in the future. Hey, ICAN, are you going to feature this story?

According to Guggie, uterine rupture is a:

… rare and an extreme emergency whether at home or in the hospital.

Not exactly. It’s far from rare, and is a known complication of attempting a vaginal birth after C-section. It is an emergency whether it occurs at home or in the hospital, but the difference is that in the hospital, they can save the baby’s life.

Even better, they can often prevent uterine rupture altogether by counseling women like Leilani that they are very poor candidates for VBAC and have a higher than average risk of this catastrophe. Had Leilani sought and followed the advice of an obstetrician, she would almost certainly be nursing and cuddling a live baby now, and probably bemoaning her “unnecessarean” as well.

This is what happens when you “trust birth.” You end up with a dead baby who didn’t have to die.

How many dead babies is it going to take before homebirth advocates realize that they have absolutely no idea what they are doing, and that precious babies are dying preventable deaths as a result of their arrogance and ignorance?

I don’t have a lot of respect for the folks at the Lamaze blog Science and Sensibility, but at least under the tenure of Amy Romano, they demonstrated more integrity than any other natural childbirth or homebirth blog:

Henci Goer has banned me: too hard to address my points. The Unnecessarean has banned me: too hard to address my points. Jennifer Block doesn’t let anyone comment on what she writes: good idea since she can’t address anyone’s points. Only the folks at “Science” and Sensibility haven’t banned me. I don’t know why since I have torn apart multiple posts that they have written. I guess that while they may not know much about science, they appear to understand integrity.

Now that Kimmelin Hull is editor, they’ve abandoned even that. Not only do they ban me, but now they’ve started deleting the factual comments of other doctors including anesthesiologist Gilbert Grant, MD. After all, when discussing the risks and benefits of anesthesia, we wouldn’t want women to be informed by mere anesthesiologists.

Last week I wrote that even though there is no evidence that epidural affects breastfeeding, Lamaze still insists on pretending that there is.

Evidently I was not the only doctor to point this out. Dr. Nick Fogelson wrote in the comments:

Please try to find the actual data that shows that epidurals have a measurable negative effect on mothers and babies. Such data is talked about a lot, but I’ve never seen it in any obstetrics journal. The reality is that there are no prospective randomized trials of epidural or no epidural, so such ‘data’ is actually either a fabricated idea or retrospective analyses fraught with bias…

Dr. Grant, the anesthesiologist, weighed in:

Based on the evidence to date, we certainly CANNOT conclude that epidurals have a causal effect of impairing breast-feeding, which is a complex activity subject to many different influences…

In a series of subsequent comments, Dr. Gilbert went on to criticize the misinformation promoted by childbirth educators (including Lamaze educators) in their classes. He provided empirical evidence that Lamaze simply fabricates claims about the “risks” of epidurals that have no basis in the scientific literature.

Well, we can’t have that, can we? Imagine, actual scientific evidence showing that Lamaze educators are deliberately teaching falsehoods about epidurals. So Kimmelin Hull deleted that complete with a pious claim that Dr. Gilbert violated the “standards” of the blog. Apparently, facts cannot be tolerated at Science and Sensibility.

Dr. Grant briefly expressed his surprise that Hull would delete factual comments simply because she preferred to keep women ignorant of those facts. That looked even worse.

Can’t have that, can we? Not only can’t Hull allow actual scientific facts, but she can’t be seen to delete actual scientific facts, so she “cleaned up” the comment thread to completely misrepresent what happened.

It looks like Dr. Grant made only 4 comments when he made twice as many. It looks like Dr. Grant never mentioned the falsehoods taught in Lamaze classes when he was quite explicit in detailing just what falsehoods are being propagated. It looks like Hull never made an attempt to address Dr. Gilbert’s data when, in fact, she offered a pitiful effort to dismiss those facts. It looks like Hull never acknowledged deleting Grant’s comments when, in fact, she acknowledged that the truth apparently “violates” the Science and Sensibility comment policy.

Hey, Kimmelin, way to demonstrate the tactics of Lamaze!

1. Write a piece that acknowledges there is no data for a central Lamaze claim.

2. Insist that it’s okay to pretend that the claim is true regardless of the lack of evidence.

3. Invite comments but be sure to censor any that provide uncomfortable scientific facts.

4. Hide evidence that you are deleting comments.

5. Rinse and repeat ad nauseum.

Wow, keeping women ignorant of the facts about childbirth is hard work!

Homebirth advocates love the word “autonomy.”

They believe that the principle of autonomy gives them the “right” to have a homebirth, and the “right” to have the provider of their choice attend their homebirth. Many also believe that they have the “right” to insurance reimbursement for their homebirth.

As with so many things, autonomy is yet another concept that homebirth advocates don’t really understand. Most seems to think that the principle of autonomy means that an individual can do whatever she wants. That’s not what it means at all. The principle of autonomy means that people are free to choose between a range of options, but it does not mean that those options are unconstrained.

Consider the Wikipedia definition of autonomy:

… [I]t refers to the capacity of a rational individual to make an informed, un-coerced decision. In moral and political philosophy, autonomy is often used as the basis for determining moral responsibility for one’s actions. One of the best known philosophical theories of autonomy was developed by Kant. In medicine, respect for the autonomy of patients is an important goal as deontology, though it can conflict with a competing ethical principle, namely beneficence…

In the medical context:

… respect for a patient’s autonomy is considered a fundamental ethical principle. This belief is the central premise of the concept of informed consent and shared decision making… In the 1940s, the phrase “informed consent” appeared … Initially, discussions about informed consent focused almost exclusively on research subjects, but eventually has come to apply to the conventional physician-patient relationship as well. The seven elements of informed consent … include threshold elements (Competence and Voluntariness), information elements (Disclosure, Recommendation, and Understanding) and consent elements (Decision and Authorization).

Simply put, the concept of autonomy means that patients must be competent and give consent voluntarily. The must receive an explanation and recommendation, and they must demonstrate understanding of what they have been told. Only the patient can make the decision and authorize the treatment.

For example, when considering treatment for breast cancer, the patient must receive an explanation of treatment options and a recommendation. Only the patient can authorize the treatment, or she can refuse the treatment. The patient can choose between surgery, chemotherapy, radiation or a combination of those options. A patient can refuse any or all of these options. But notice what autonomy does NOT encompass.

Autonomy does NOT mean that her doctor is required to offer pseudoscientific or unapproved treatment.
Autonomy does NOT mean the doctor must provide her treatment at home.
Autonomy does NOT mean that the patient can choose her own provider to administer chemotherapy or perform surgery.
Autonomy does NOT mean that the government must offer a license to practice to anyone the patient feels is qualified.
Autonomy does NOT mean that insurance companies must pay for pseudoscientific or unapproved treatment.

In other words, the principle of autonomy means that a woman diagnosed with breast cancer has a right to accept or refuse the recommended options, and a right to a complete explanation of the risks and benefits of those options.

Moreover, while a patient has the right to choose a pseudoscientific or unapproved alternative “treatment,” and the right to administer it to herself, it does NOT mean that the medical profession, the government or anyone else must facilitate that right.

When it comes to homebirth, the principle of autonomy means that a woman has the right to refuse obstetrical interventions and the right to refuse to go to the hospital at all. Here’s what it does NOT encompass:

Autonomy does NOT mean that her doctor is required to offer pseudoscientific or unapproved treatment.
Autonomy does NOT mean the doctor must provide obstetrical care at home.
Autonomy does NOT mean that the patient can choose her personally designated “midwife” to attend her birth.
Autonomy does NOT mean that the government must offer a license to practice to anyone the patient feels is qualified to be a midwife.
Autonomy does NOT mean that insurance companies must pay for her homebirth.

The bottom line is that the principle of autonomy means that a woman does not have to go to the hospital to have a baby, but it means nothing beyond that.

Opponents are clear about one thing; women don’t understand the risks. They aren’t giving informed consent because they aren’t fully informed. Sure, they may be counseled about the major risks, the ones that could kill you, but deaths are rare. The other complications are so much more common. If women only knew the myriad risks they faced, they’d never choose it in the first place.

Opponents recommend far more extensive counseling, preferably counseling that takes place long before the decision needs to be made. They helpfully offer books and websites as well as in person counseling about ALL the risks, not just the ones that doctors deign to mention. Doctors can’t be relied upon to provide truly informed consent since they have a conflict of interest. They’re the ones who make money if the woman elects the procedure.

Inevitably there has been a backlash against the opponents but the opponents claim the high ground with the retort: “Are you saying that there are NO risks?” Everyone knows that there are risks and that comment exposes those in favor as being the lying, evil people that they are. Opponents are providing a valuable service by carefully and extensively counseling women about the risks. Once they know, they will turn down the procedure.

Think I’m talking about natural childbirth advocates and epidurals? Think again.

I’m talking about anti-choice advocates who work tirelessly to prevent women from choosing abortion.

It’s not a coincidence that NCB advocates have taken a page from anti-choice activists. They both have the same aim: to conceal their true purpose while pretending that they are concerned about informed consent, trying to place any and all obstacles to the procedure in the path of women who might choose it.

Neither group feels constrained by the truth. Reasoning that the ends justify the means, both groups routinely exaggerate and even fabricate “risks.” Seeking, above all else, validation of their personal philosophical beliefs, both groups struggle to convince women who would choose differently that those choices are wrong. Focussed entirely on preventing the procedure, both groups have zero regard for what happens to women once they reject the disapproved choice. They care about women up to the moment that they are forced into the “correct” decision; whatever happens afterward must simply be endured by the women they have duped.

Most of is can easily recognize the tactics of anti-choice activists for what they are, mendacious attempts to force women to make approved decisions. Most of us can easily recognize that the pregnancy “support” centers have no interest in supporting pregnancy and certainly have no interest in supporting the babies that result from those pregnancies. They are exclusively concerned with foisting their philosophical views on everyone else. Their pious bleating about “informed consent” masks their true motivation.

We should recognize the tactics of NCB advocates for what they are, mendacious attempt to force women to make approved childbirth decisions. We should recognize that NCB “education” has nothing to do with supporting women in finding the choice that is best for them. Advocates are exclusively concerned with foisting their philosophical views on everyone else. Their pious bleating about “informed consent” masks their true motivation.

Yesterday’s post on the inaptly named Lamaze blog Science and Sensibility acknowledged that, contrary to the fervent wishes of natural childbirth advocates, there is NO EVIDENCE that epidurals interfere with breastfeeding.

But why let a little thing like evidence stop you? The Lamaze blogger helpfully offers a series of ridiculous reasons why NCB advocates can continue to pretend otherwise.

The blogger, Sylvie Donner, starts with a review of the literature. She notes that the studies that purported to find a link between epidural and breastfeeding were small, retrospective and of low quality. The rest of the literature finds no link between epidural and breastfeeding, or draws no conclusion after noting the fact that confounding variables make it impossible to determine whether there is a relationship.

None of this is the least bit surprising to obstetricians and anesthesiologists. When narcotics are injected along with local anesthetics into epidural catheters, only a tiny amount reaches the maternal bloodstream and an even tinier amount crosses the placenta. Epidural narcotics do not sedate mothers; therefore, it makes no sense that they would sedate the babies who receive a far lower concentration.

So there is no evidence that epidurals impact breastfeeding and no physiologic explanation for why they would affect breastfeeding, but the folks at Lamaze really, really, really want to believe that epidurals are BAD. Donna tries to help them out:

Common sense might lead us to view even these studies which find no link between epidurals and breastfeeding with some caution.

Of course, I’ve just explained that common sense would support the fact that there is no link between epidurals and breastfeeding because there is no evidence that babies would be sedated by tiny fractions of the same medications that do not sedate their mothers. But “common sense” among homebirth advocates apparently isn’t that common and doesn’t make much sense.

After all, the following need to be taken into account as well:

Epidurals are associated with a general medicalization of birth (since they usually and/or frequently involve IV lines and urinary catheters, as well as electronic fetal monitoring and ongoing monitoring of blood pressure) and this may contribute to greater maternal discomfort postnatally, meaning that breastfeeding could be affected.

Ahh, yes, the dreaded “medicalization.” It may make women uncomfortable in labor and breastfeeding could be affected! Really? How? No explanation is given.

Epidurals are known to be associated with a higher rate of instrumental delivery and caesarean.  Postpartum perineal discomfort, or pain as a result of abdominal surgery, will also inevitably make breastfeeding less comfortable, and therefore less likely to occur.

Of course there is no evidence that perineal or abdominal discomfort “inevitably makes breastfeeding less comfortable” but why not pretend? How about the fact that breastfeeding itself is often uncomfortable? That, apparently, is completely irrelevant. Any caring mother would ignore cracked and bleeding nipples, but perineal pain? OMG, who could be expected to endure that?

Epidurals can influence the fluctuation of hormone levels that play an important role in breastfeeding.

Look ma, no evidence! Oh, wait, there was a study that showed that epidurals might possibly affect the interaction between the adrenals and the pituitary. And the pituitary produces other hormones … and prolactin is one of those hormones … so if the epidural could affect one hormone, it could affect them all!!!

Furthermore, most studies conducted so far are unlikely to have compared physiological, unmedicated active labor with epidural labors. Comparing breastfeeding success after epidural birth to opiate-medicated birth (or birth with other forms of analgesia, such as Entonox) is not the same as comparing physiological birth to epidural birth.

 How do we know they are different? Duh! Because Lamaze says so. And how do we know those “differences” have any impact on breastfeeding? Duh! Because Lamaze says so.

The conclusion is inevitable. Just because there is no evidence to show that epidurals have no impact on breastfeeding, we can still pretend that they do.

After all, any other conclusion is completely unacceptable. Epidurals are bad, bad, bad, so they must interfere with breastfeeding or else the folks at Lamaze will be sad, sad, sad.