I’ve participated in a number of on line discussions this week, and although the topics vary and identity of the homebirth advocates vary, one thing is always the same. When I mention that MANA is hiding the number of babies who died at the hands of CPMs, the silence is deafening.

Most homebirth advocates try desperately to pretend that I didn’t say it. They don’t deny that MANA (the Midwives Alliance of North America) is hiding the death rates at 18,000 homebirths attended by CPMs (certified professional midwives, formerly known as lay midwives). How could they? They don’t respond. What could they say? Instead they try to ignore this glaringly unethical behavior and hope that women will forget they ever heard about it.

Finally, though, someone decided to take a stand. Amie Newman, who blogs for RH Reality Check, explained why it is okay for MANA to hide the number of babies who died. After tangling with me through several back and forth comments, Newman wrote:

I 100% believe that women deserve the right to know how safe planned homebirth is with a Certified Professional Midwife. I also 100% believe that we have that information currently.

I replied:

You believe that we know the number of babies who died at the hands of CPMs in the 18,000 case MANA database?

Well, if you know the number, don’t keep us in suspense! Exactly how many babies died at those 18,000 CPM homebirths?

Or … will you simply acknowledge the obvious: we don’t have that information, MANA is hiding it, and you think it’s just fine for MANA to hide their own death rates from American women if those death rates are appallingly high.

At that point Newman simply stopped responding.

Honestly, I simply cannot fathom how a site that exists to support reproductive rights can produce a blogger and commenters that think women have no right to accurate information about the death toll of homebirth. Of course they join a long list of homebirth advocates who blithely ignore the issue that MANA is hiding homebirth deaths.

Ina May Gaskin thinks it’s just fine if MANA hides the number of homebirth deaths from American women.

Jill Arnold of the Unnecesarean claims to believe that “all maternity care data should be readily accessible to consumers and the general public,” but apparently thinks that does not apply to MANA.

Gina Crossley-Corcoran, the Feminist Breeder, offers the usual homebirth prattle without recognizing the irony:

I thought providers took an oath to help people? Putting their business ahead of reproductive choices isn’t keeping anybody safer, and the science proves that. Shame on them for ignoring the vast body of evidence from their own collegues.

Yes, shame on MANA for HIDING the vast body of evidence about homebirth deaths from their own colleagues, but especially from American women.

And Danielle Ellwood, the blogger who wrote the original piece on Babble performed the typical homebirth flounce:

Today, in true internet style… the poster [Dr. Amy] who started it all tried to call me out, and this is when I knew I needed to have my final word.

“And where’s Danielle who claims to care so much about mothers and babies? Why isn’t she demanding that MANA release their death rates?”

… Reply?

@Amy – There is no reasoning with someone like you. I care about women, I work on a local level, I work in my community, and I have actively been working for better maternal outcomes since entering the birth community 6 years ago, before even having my first child.

I am not going to feed into this debate anymore because it is clearly useless…

I am done.

In other words, she had painted herself into a corner and was too embarrassed to continue. Plus, she has all the right “birth cred” and everyone knows that means she really, really cares about women.

For these women and other homebirth advocates, I have a message:

You should be ashamed of yourselves.

Stop pretending! We all know that those statistics are being hidden because they show that an appalling number of babies died at homebirths with CPMs. Otherwise MANA would have published them and sent out a thousand press releases to boot.

It is time for American women to learn the truth about homebirth deaths, and homebirth advocates should be the first to call for transparency, not the first to offer the pathetic excuse that women already have all the information they need.

Sigh. Another day, another goofy Science and Sensibility post.

It may be a new year, and there may be a new editor, but the Lamaze blog appears to have merely traded one form of incompetent analysis for another. The previous editor Amy Romano, CNM, left to take a position with the lobbying organization Childbirth Connection. The new editor is Kimmelin Hull,

a Lamaze Certified Childbirth Educator, Physician Assistant, American Red Cross First Aid/CPR instructor, novelist and freelance writer for local and international parenting magazines.

In other words, she has no experience in caring for pregnant women, has no background in science or statistics, and essentially no qualifications for analyzing scientific literature. Not surprisingly, she’s off to a very unimpressive start.

Her first blunder didn’t even involve science. She wrote with a piece praising the Lamaze policy on conflicts of interest. Explaining why she declined to teach a class on breastfeeding at a local store, she wrote:

The slippery slope, however, became evident in this business owner’s expectation that the content of my presentation would directly entice class participants to buy certain products, based on my recommendations under the guise of authoritative knowledge.

But then I asked:

So why does Lamaze International license and recommend baby toys, women’s body lotions and women’s apparel? Clearly is trying to women to buy certain products based on their recommendations and under the guise of authoritative knowledge.

Cue the backpedaling. Hull tried to make an exception:

… if you truly believe in the healthy, helpful aspect of a product/service, providing information on it (or samples of it) to your clients becomes an act of “helping” vs. “promoting.” …

We’re supposed to believe that Lamaze collects licensing fees on baby toys, women’s body lotions and women’s apparel because they like “helping”?

Today Hull tries her hand at analyzing a scientific paper, The impact of maternal age on fetal death: does length of gestation matter? published in the December issue of the American Journal of Obstetrics and Gynecology. The authors found that women 40 and older had the highest risk of fetal death throughout pregnancy.

Hull accurately explains the methodology and findings of the paper, but then offers this startling assertion:

… other factors that have not garnered much attention in the literature but, in my estimation, certainly influence a woman’s general state of health and well-being (and thus potentially, the health of her pregnancy) are factors such as: diet, exercise routine and overall stress level. Designing a future study which could control for these additional variables would undoubtedly alter the data tremendously …

What??!! In her estimation? Based on what evidence? Apparently none.

Hull really, really wishes that advanced maternal age did not increase the stillbirth rate, so she is casting about for reasons she can ignore the evidence. Hmmm, let’s pretend that some easily modified factors (diet! exercise! stress!!) negate the impact of maternal age. Oooh, that sounds good! And as long as we’re pretending, let’s go all the way: these variable would undoubtedly alter the data tremendously! Really, Kimmelin?

Hull then proceeds to offer the “tremendously” altered data. Too bad she just made it up. But wait! She’s not finished making things up:

Despite the mention of induced labors being included in the cohort, there are no numbers on how many of the 2 million + pregnancies ended in induction—leaving a potentially HUGE confounding variable unchecked.

Yes, inductions may be a confounding variable because they REDUCE the risk of stillbirth. If inductions are a confounding variable, correcting for them would INCREASE the association between advanced maternal age and stillbirth, not decrease it, as she mistakenly believes.

The editor may have changed, but the quality of the scientific analysis at Science and Sensibility is still pathetic. Here’s some helpful advice: If you are going to dispute the results of a scientific paper, you need to offer scientific evidence to support your claims. Merely pretending the results aren’t true if they don’t fall in line with your personal beliefs does not represent scientific analysis, merely the wishful thinking that is so characteristic of contemporary NCB advocacy.

Years ago I wrote a brief piece about homebirth midwifery entitled Whatever the scientific evidence shows, do the opposite. It turns out that I was echoing a feminist criticism of the “new” midwifery.

Among the most influential commentators on the subject are Ellen Annandale and Judith Clark, authors of the widely quoted paper, What is gender? Feminist theory and the sociology of human reproduction published in Sociology of Health & Illness Vol. 18, No. 1, 1996. The paper is long and filled with academic jargon, but has important insights that have created controversy among feminist theorists. The heart of Annandale and Clark’s criticism of the new midwifery is almost exactly the same claim that I made:

… the lived experience of midwifery … is revealed only as the largely unresearched antithesis of obstetrics. An alternative is called into existence in powerful and convincing terms, while at the same time its central precepts (such as ‘women controlled’, ‘natural birth’) are vaguely drawn and in practical terms carry little meaning.

This is a stunning criticism. Midwifery is described as unscientific and based on reflexive defiance. How did the new midwifery get to this point? Annandale and Clark believe that it starts with biological essentialism. They approvingly quote the work of a colleague:

… what both feminists and phallocentrists see as hegemony based on masculine perceptions of domination, performance, hierarchy, abstraction, and rationality, finds its antipode in a woman’s community proclaiming itself as naturally nurturant, receptive, cooperative, intimate, and exulting in the emotions . . . [feminists] assume that such principles exist and that they have been fixed and dichotomous since the dawn of patriarchal history. . . . Thus it is that the dominant culture and the counterculture engage in a curious collusion in which . . . a rebellious feminism takes up its assigned position at the negative pole.

Peeling away the jargon leaves us with the basic point, biological essentialism perpetuates women’s oppression by validating men’s belief that women are emotional and irrational. Or as Annandale and Clark write:

… Thus … reproduction is still centred for women and put on the agenda as if it were central to all women’s lives. This may serve to lock women into reproductive roles which may be politically problematic since the centrality of reproduction, contraception and childbirth to biomedicine is transferred to women’s experiences. This may be the reality of their experience, but equally importantly, it may not. To a certain extent this may be seen as an unavoidable consequence of a critique which appears as if it must engage the dichotomies of biomedicine to develop its own narrative.

The authors identify Sheila Kitzinger as an exponent of this false dichotomy.

‘Altematives’ to male-biomedicine were heavily valorised in research in the 1970s and 1980s. This was particularly evident in suggested alternatives to mainstream gynaecological and obstetric care. Sheila Kitzinger, for example, wrote that

the new midwifery has a vital part to play in the woman’s movement and is at the very centre of the great creative upheaval which is taking place as we reclaim our bodies and come to learn about, understand and glory in them. This new midwifery gives vivid expression to the way in which women are discovering strength and sisterhood as we turn to help and support one another during the intense, exhilarating and powerful experience of childbirth (1988:18).

A clear line of demarcation tends to be drawn in the literature between obstetrics and midwifery: each is portrayed as a unitary and intemally coherent body of thought and practice which is at odds with the other. The ‘alternative’ female-midwifery is clearly put forward as the better model…

Not only are such assumptions wrong, they are also elitist:

… The charge of elitism evidenced in the privileged white middle-class voice of much research, and the silence around differences between women, applies well to Barbara Katz Rothman’s influential 1982 work … which ends with an implicit call for a home-based natural birth experience …. This is made in joyous terms with little recognition that many women may not be in the position to avail themselves of such an ‘alternative’ even if they wanted to.

Annandale and Clark ask a critical question about the new midwifery. Are midwives “with women” or exploiting women for their own ends?

If we conceive of power as a fundamentally male preserve we are led to gloss over ways in which women may exert power over others, including other women . In these terms, as recent institutional reforms stimulate community midwifery midwives may begin to consider the notion of affinity with women embedded in such concepts as ‘continuity of care’ … as masking the potential exploitation of midwives by their clients.

Who, after all, is being served by this concept of midwifery?

In my view, the ultimate irony of the new midwifery is that the very people who bemoan the supposed inability of modern obstetrics to cooperate with midwifery are the very people who have made such cooperation impossible.

By insisting that all women are the same, that childbirth has a biological “essence” that must be preserved and, especially, that midwifery is defined by its opposition to modern obstetrics, midwifery theorists have created a false dichotomy that is by definition unbridgeable. Midwifery theory ignores the interests of many, if not the majority of women. Indeed, the new midwifery goes beyond ignoring women who refuse to subscribe to the theory of biological essentialism and questions the very “authenticity” of their womanhood and motherhood.

Most women in contemporary first world countries have rejected essentialism, embrace technology, and have no use for a philosophy that presumes that midwifery exists only insofar as it rejects defies modern obstetrics. If midwifery is to survive, midwifery theorists had better wake up to that reality and stop pretending that unreflective defiance is a virtue.

A surprising number of childbirth websites are run or staffed by childbirth educators, which is rather surprising, since they entirely lack the education, training, and experience to provide scientifically accurate, unbiased information. It’s the equivalent of a civil war website run by the Daughters of the Confederacy. They may be passionate, but they are last people who you would expect to be knowledgeable about the details and unbiased in their transmission of information. But why bother any of that, when it is well known cliche that those who can’t do, teach.

Who are childbirth educators, and what makes them think they are qualified to advise other women?

There are no requirements for becoming a childbirth educator. According to prominent childbirth educator Robin Elise Weiss, who dispensse her personal views on childbirth at a variety of websites:

… [A]lmost anyone can become a childbirth educator (CBE). You do not need to be a nurse, a midwife, or a doula. You really need a more than basic level of knowledge of childbirth …

In fact, you only need 16 HOURS of childbirth education, including indoctrination is the ideology of the certifying organization. According to the International Childbirth Education Association, those 16 hours comprise:

Part I – Family-Centered Maternity Care (FCMC) and the Role of the Childbirth Educator
Part II – Anatomy&Physiology of Preconception, Conception and Pregnancy
Part III – Nutrition for the Childbearing Year and Infant Feeding
Part IV – Psychosocial/Emotional Changes in Pregnancy, Abuse Issues
Part V – Labor and Birth
Part VI – Labor Coping Skills
Part VII – Obstetrical Tests and Procedures
Part VIII – Cesarean Birth and Vaginal Birth After Cesarean (VBAC)
Part IX – Postpartum and the Newborn
Part X – Teaching Skills

In other words, less than 2 hours apiece are spent on the massive subjects of labor and birth, obstetrical tests, and C-section and VBAC. That would be fine if childbirth educators limited themselves to giving women basic familiarity with what is likely to happen during pregnancy and labor. Unfortunately, childbirth educators do not limit themselves to what they could reasonably do. Instead, they offer medical advice, criticize obstetric procedures, promote ideology above science, and proselytize for their personal preference. And for those tasks, they are entirely unqualified.

Childbirth education organizations are also like the Daughters of the Confederacy in that they make no effort to hide their bias. The ICEA calls its philosophy “Family Centered Care” which is a misnomer for the biological essentialism at the heart of their philosophy.

Family-centered care consists of an attitude rather than a protocol. It recognizes a vital life event rather than a medical procedure… It realizes that the decisions she may make are based on many influences of which the expertise of the professional is only one…

So childbirth educators promote a specific “attitude,” refuse to acknowledge the inherent dangers of pregnancy and childbirth, and seek to undermine the patient’s trust in her care providers. And all without any real education in anything!

That’s just generic childbirth educators. Women who are certified by specific organizations like Lamaze must subscribe to the beliefs of the Lamaze organization. Lamaze requires:

Competency 1: Promotes the childbearing experience as a normal, natural, and healthy process which profoundly affects women and their families.
Competency 2: Assists women and their families to discover and to use strategies to facilitate normal, natural, and healthy pregnancy, birth, breastfeeding, and early parenting.
Competency 3: Helps women and their families to understand how complications and interventions influence the normal course of pregnancy, birth, breastfeeding, and early postpartum.
Competency 4: Provides information and support that encourages attachment between babies and their families.
Competency 5: Assists women and their families to make informed decisions for childbearing.
Competency 6: Acts as an advocate to promote, support, and protect natural, safe, and healthy birth.
Competency 7: Designs, teaches, and evaluates a course in Lamaze preparation that increases a woman’s confidence and ability to give birth.

No one could accuse them of keeping their biases secret, either. In addition to promoting “natural” birth (i.e. biological essentialism), they think they are supposed to promote breastfeeding and attachment parenting, and act in opposition to actual care providers when their personal view of childbirth is threatened.

We would be outraged if a school system in in the South insisted that as a a requirement for certification, history teachers promote state’s rights, and protect the belief that slavery wasn’t that bad. We should be equally outraged that the field of childbirth education has been hijacked by women who have no intention of providing unbiased information and view their job as explicitly favoring certain childbirth and mothering choices above others.

Childbirth educators seek to change obstetrical care to reflect their personal preferences, but they can’t do (change it from within by becoming a midwife or obstetrician), so they teach.

I try to follow as many natural childbirth pregnancy blogs and websites as I can to keep up to date on what women are reading across the web. As I have repeatedly noted, most of them are chock to the brim with misinformation, misleading information and wacky “information.” Occasionally I will comment when I see a particularly egregious example, like a recent blog entry about maternal mortality on Babble. I have written a great deal on the subject (Hold the handwringing: is maternal mortality really rising?) and wanted to correct the manifold errors in the piece.

No, maternal mortality is NOT rising. It has fallen in 2006 and fallen again in 2007 to 12.7/100,000, facts that this piece completely ignores.

Moreover, it is far from clear that maternal mortality was ever rising. A careful review of the data suggests that changes in the way that maternal mortality is assessed may be leading to a spurious “increase” in maternal mortality.

The author of the piece had no response, not surprisingly, but the other day Ina May Gaskin parachuted in, once again attempting to cynically exploit this tragic issue as she has been doing for years on her “Remember the Mothers” website. She calls for “honesty” and then proceed to offer a bunch of out of date bibliography salad and never addresses any of the issues that I raised.

Here are just a few examples of articles that have been published during the last decade or so about the too high US maternal death rate: “Pregnancy-related deaths: Moving the wrong direction,” published in OBG Management, January 1998; “Maternal mortality: No improvement since 1982.” ACOG Today, August 1999; Maternal mortality: An unsolved problem. Contemporary Ob.Gyn, September 1999; “U. S. maternal death rates are on the rise.” The Lancet, 1996; “Pregnancy-related deaths increasing,” Contemporary Ob.Gyn, December 2010.

To anyone who knows anything about obstetrics, this bibliography salad is not only out of date (newsflash: anything before 2000 is NOT in the last decade, and, considering that we are discussing maternal mortality from 1998 to 2005 has absolutely nothing to do with this purported rise), but it is laughable. OBG Management, ACOG Today and Contemporary Ob.Gyn are what is known as “throw away” magazines. They are not journals, and they are mailed to almost all obstetricians for free. It’s the equivalent of citing “House Beautiful” to make a claim about architecture.

Ina May was obviously cutting and pasting from out of date claims she has made in the past (she accidentally pasted twice), and actually makes my point for me:

Prior to 2003, only 2 states used the US Standard Death Certificate—the only one containing the questions that CDC epidemiologists designed to prevent misclassification of maternal deaths. Many states still refuse to use the standard death certificate. This makes the CDC’s data much less accurate and useful than they should be for such an important statistic. Underreporting maternal deaths leads to a false sense of security and misunderstanding of the true causes of preventable deaths.

Yes, Ina May, that’s just what I said. Prior to 2003,there was considerable under-reporting of maternal deaths. And just as under-reporting can lead to misunderstanding about the scale of maternal mortality, correcting that under-reporting can lead to a spurious “increase” in maternal mortality.

Babble began promoting the exchange on Twitter:

Are you team Ina May Gaskin or Dr. Amy? See what they have to say about pregnancy related deaths in the U.S.

I responded to Ms. Gaskin:

You represent yourself as shocked at the current rate of maternal mortality. Yet as far as far as I can tell, direct entry midwives in general and you in particular have done NOTHING (no research, no education, no fund raising) to reduce the incidence of maternal mortality. In contrast, modern obstetrics has lowered the maternal mortality rate 99% PERCENT in the past century…

Anyone who visits your “Remember the Mothers” website will notice something rather curious. There is NO information about the causes, treatments and research into maternal mortality…

… You want to leave the impression that maternal mortality is caused by obstetric interventions…

The reality, as you OUGHT to know, iatrogenic deaths represent a tiny fractions of maternal mortality. The most common causes of maternal mortality are complications of pregnancy and pre-existing medical conditions.

You should be embarrassed at the way that you have deliberately misrepresented the issue for your own personal ends.

Then Ina May ran away. I’d like to think she was ashamed, but I doubt it. She had simply used up everything she had to say on the subject (relevant and irrelevant) and had no response. Like all professional natural childbirth advocates, she was not going to engage in a debate that required her to defend her claims.

Earlier this week I wrote about the fact that contemporary midwifery has been hijacked by biological essentialists and feminist anti-rationalists. I’m not the first to notice that this has compromised the care that midwives provide to women.

Canadian midwife Mary Sharpe and colleagues have written about the situation in Ontario in Essentialism as a Contributing Factor in Ideological Resonance and Dissonance Between Women and Their Midwives in Ontario, Canada. Sharpe starts with a definition of essentialism:

Essentialism is understood as the tendency to view entities according to a set of distinct and limiting characteristics, or essences. Furthermore, an essentialist approach regards these characteristics or essences as inherently true or correct…

Sharpe details how essentialism is expressed in the foundational documents of Ontario midwives:

While the values embedded within the document, when viewed pragmatically, simply set ideals for practice, they also tend to support the culture of essentialism within the midwifery community by making certain assumptions about the meaning of midwifery care, the women who seek midwifery care and the nature of the woman-midwife relationship…

But those beliefs and assumptions are not shared by a large proportion of women. Instead of acknowledging that essentialist beliefs are not held by all women, the Ontario midwives react with disdain and an unwillingess to care for women who have different beliefs.

While some midwives interviewed stated that they were delighted to be able to provide care for the more diverse group of women seeking midwifery care … they nevertheless noted that they remained wary of those who do not overtly behave in ways that correspond to Ontario midwifery’s stated values and philosophies… Some Ontario midwives indicated that they felt there are “ideal” or “peak” midwifery clients and that certain women are therefore particularly “deserving” of midwifery…

As midwife Vicki Van Wagner explains:

There is a real tension in the midwifery community between narrow essentialist views of women, midwives and birth, connected with the lure of the “natural” and other concepts such as choice and diversity… In a countercultural movement such as midwifery, the need for strength to combat outer forces can create narrow views, dogmatism and a fear of diversity…

Sociologist Helen Lenskyj notes:

It does not serve women’s interests well for midwifery supporters to essentialize women as either mothers or midwives… Where does this leave the non-conforming mother who does not view the midwife as her best friend … One [also] needs to consider the messages that [such] rhetoric convey[s] to a woman who has no … regrets about her conventional medicalized birth experience. Is she less female/ feminine/ feminist because she does not … reflect on [her] birth experiences with feelings of anger, regret, mourning and loss?

Ultimately:

Ontario’s model of midwifery care reflects the essentialist tendencies of the feminist movements of the 1970s and 1980s that led to the legislation of midwifery in Ontario… The essentialist tendencies revealed by midwives and women in Sharpe’s study tend to pose dilemmas for midwives in the manner in which care is provided, the manner in which women are selected for care and the ways in which the philosophy of midwifery care is upheld.

Helen Lenskyj offers midwives advice that they should take to heart:

It is not productive for midwifery’s advocates to cling to exclusory or essentialist notions of woman and midwife. Rather, it is important to respect the feminist principle of choice … and to allow for diversity and difference among women, both midwives and clients.

What I find most intriguing about the views expressed in this paper is that they highlight the fact that midwifery has become obsessed with the feelings of midwives to the detriment of patients. It suits certain midwives and virtually all midwifery theorists to claim that “the natural” represents the pure essence of what women should want and how women should behave.

The profession of midwifery has been led astray from the values that have preserved midwifery across time, place and cultures. Those values were to minimize the risk of death to baby and mother by observing the ways that treatments and preventive measures could improve outcome. In contrast, contemporary midwifery often seems devoted to a stylized piece of performance art where the process is viewed as more important than the outcome. It is ironic that a profession that proposed in the mid-twentieth century to offer women more choices has devolved into a profession that insists that only one choice is acceptable.

In a gesture worthy of Marie Antoinette, the head of the Royal College of Midwives, Cathy Warwick, has reviewed the growing problem of women being turned away from hospitals when in labor and demanded greater access to … homebirths.

Marie Antoinette, you may remember, when confronted with starving thousands demanding bread famously declared “let them eat cake.” That simple phrase crystallized how entirely out of touch the French queen was with the condition of her people. Similarly, Cathy Warwick, on being confronted by the reality that there are not enough staff and equipment to provide care for women in labor now declares that what midwives women really need is access to a specialized service that is appropriate for only a tiny proportion of the population and represents a dreadfully inefficient use of scarce resources.

Consider the problem. According to a report in the Daily Telegraph, Two women every day ‘being turned away from overstretched maternity units’:

Almost 750 heavily pregnant women were forced to travel to other units, up to 100 miles away, to give birth last year.

Almost half of the women who were sent to other units were in Greater Manchester, where four maternity units are facing cuts, the figures show.

The figures have been uncovered by the Conservatives using the Freedom of Information Act.

They also show that many maternity units had been forced to close to new patients more than 10 times in 2009.

The Royal College of Midwives (RCM) estimates that an extra 5,000 midwives are needed across England to provide just a decent standard of care.

Faced with these statistics, that there are not enough midwives to care for multiple women at a time in hospital units, Cathy Warwick thinks that what midwives women really need is greater access to a service that is only appropriate and desired by a tiny fraction of women and which requires not one, but TWO midwives, to attend a single patient, far away from all the other patients who need care.

The BBC reports today that Cathy Warwick acknowledges that maternity services in the UK are “stretched to the breaking point” but offered this bizarre response:

“We want to make sure that all women know that the choice of a home birth is available to them.

“We feel that there is a concerted and calculated backlash by sectors of the establishment against homebirth and midwife-led care.

“We are not sure what the coalition Government’s position is on home birth – or whether they are honouring their pre-election promises for adequately staffed maternity services for 3,000 more midwives.

“To begin providing more home births, there needs to be a seismic shift in the way maternity services are organised.

“The NHS is simply not prepared to meet the potential demand for home births because we are still embedded in a medicalised culture.

“The recently reported drop in the home birth rate in England from 2.9 % in 2008 to 2.7% in 2009 is a real disappointment.”

So let me get this straight. There are not enough midwives to provide the most basic level of care for pregnant women in the UK, and Cathy Warwick thinks the response should be to encourage women to demand that two midwives attended each woman at home while many other women have no care at all?

The problem is a “medicalised culture”? Evidently not since many women cannot access any care, let alone “medicalised” care.

And the drop in the homebirth rate is a “real disappointment”? For whom? No doubt the bakers in Marie Antoinette’s France were disappointed that the starving were not buying lots of cake, too, but that doesn’t mean that their distress was the problem that should have received priority..

Who is this woman? We met Cathy Warwick this past summer when the UK’s leading midwife was caught making up facts. Once again promoting the benefits to midwives women of homebirth, Warwick declared that we should look to the Netherlands, where 30% of women give birth at home and where perinatal mortality is the lowest in Europe. Since the Netherlands has the HIGHEST perinatal mortality rate in Europe that statement was either an expression of profound ignorance or a bald-faced lie. Indeed, the newspaper that conducted the interview was forced to print a retraction of Warwick’s fabricated claim.

Cathy Warwick epitomizes that self-serving blatherer that characterizes contemporary British midwifery: the biological essentialist who believes that “natural” birth is more important than safe birth, the anti-rationalist who invokes “quantum theory” to explain why scientific evidence should be ignored in favor of midwives’ opinions, the self-absorbed, self-referential, selfish woman who pretends that the needs of midwives are the same as the needs of women.

Cathy Warwick and the Royal College of Midwives should be ashamed of themselves.

What do Jenny McCarthy, Riki Lake and Susan Somers have in common (beside the fact that they are B movie starlets who give medical advice)? All three women, like all believers in pseudoscience, suffer from logophobia. That’s right, they have a pathological fear of logical thought.

It actually goes deeper than a simple fear of logic, however. The real object of their fear is rationalism itself. Indeed, the term logophobia was jokingly coined by Nicholas Shackel to describe a serious phenomenon. In his paper The Vacuity of Postmodernist Methodology, Shackel explains that logophobia arises from:

… a sceptical doctrine about rationality (which they mistake for a profound discovery): namely, that rationality cannot be an objective constraint on us but is just whatever we make it, and what we make it depends on what we value….

Or, as philosopher Massimo Pigliucci succinctly observed:

In other words, they claim that reason cannot possibly solve every problem, so you can proceed with dismissing reason altogether.

Unfortunately, logophobia is widespread:

[It] can strike adult humans of all ages, genders and cultural backgrounds, especially when they have never been seriously exposed to the basics of critical thinking, or when they have grown up in the thralls of a powerful ideological system. The disease is preventable by early education, although it requires painful effort on the part of teachers and students alike. Once the subject is past middle school, it becomes increasingly difficult, and in most cases essentially impossible, to provide a cure; huge amounts of financial resources and time are wasted as a result.

There’s a version of logophobia that is particularly endemic among midwifery theorists. Midwifery logophobics are not timid about their anti-rationalism. Consider a recent paper entitled Beyond evidence-based medicine: complexity and stories of maternity care by Soo Downe, the doyenne of goofy midwifery theory. Evidence, a key requirement of rational argument, does not comport with the central claims of midwifery practice, so, of course, the very concept of evidence must be discarded:

From a Khunian perspective of ‘normal science’ as a social construct, current authoritative science thinking in medicine and health care has, until very recently, been strongly rooted in positivism. This has translated into a hierarchy that strongly favours the randomized controlled trial, based on the concept that bias in any experiment will corrupt the result…

Despite the entrenched acceptance of normal science in health care, it appears that authoritative, positivist, linear, risk averse, certainty-based thinking can only get us so far along the route of optimum health. This paper … illustrate[s] how maternity care clinicians can be introduced to [another way of] thinking through reflexive analysis of real life clinical narratives… a basis for answering the question, what is likely to work for this person, in this situation, given the range of evidence, and given their values and beliefs, my values and beliefs, and my clinical skills and knowledge?

It is truly remarkable how closely this adheres to Shackel’s explanation of logophobia: midwives shouldn’t be constrained by rationality, because rationality does not support many of the claims of midwifery. Since reality is nothing more than what midwives make of it, midwives based can base their “own” reality on what they value. And what they value is their personal beliefs about childbirth.

Those who value rationality, who are logophiles instead of logophobes, should not stand by idly while midwifery theorists brazenly attempt to replace science with “stories.”

As Piglucci reminds us:

… fighting the spread of logophobia is a primary responsibility of every critically thinking person and practicing scientist, despite the highly unfavourable odds against defeating it — which is why a thorough knowledge of the disease and of its symptoms is so crucial.

In the case of childbirth, this means a thorough knowledge of modern obstetrics, basic science and statistics. That’s why this blog exists: to fight the good fight against logophobia in contemporary childbirth discourse.

The Big Push Campaign runs one of the most visible drives for licensing of CPMs (certified professional midwives also known as direct entry midwives). According to their website:

The Big Push campaign all began on the Birth Policy Yahoo Group, established in 2004 by Katie Prown, PhD, a birth activist who was one of the leaders of the successful efforts to achieve CPM licensure in Wisconsin in 2006, and a pivotal leader in the larger movement.

Who is Katie Prown?

… A consultant, press liaison and advocate for organizations developing legislation to license Certified Professional Midwives (CPMs), Katherine is the Campaign Manager of the Big Push for Midwives Campaign. As Legislative Chair for the Wisconsin Guild of Midwives, Katherine drafted legislation to license Certified Professional Midwives in Wisconsin and co-led a statewide, bi-partisan grassroots advocacy campaign to successfully pass the bill into law in 2006. In support of that effort, she founded Wisconsin Birth Options, a statewide grassroots network devoted to maternity care reform in Wisconsin.

Prown speaks widely and often about the purported safety of homebirth with a CPM. Curiously she never mentions that Wisconsin collects statistics about homebirths and year after year those statistics show that homebirth triples the rate of neonatal death.

I have tangled with Prown in the past. I posted the Wisconsin neonatal mortality statistics in a comment thread on a Newsweek article about midwifery which quoted Prown, asking why she did not mention that homebirth midwives in Wisconsin had triple the neonatal death rate of low risk hospital birth. Here’s Prown’s reply:

The Wisconsin statistics that Dr. Amy cites are irrelevant… [T]hey were compiled before Certified Professional Midwives in the state attained legal status (which happened in May, 2007)…

But now the statistics for 2008 are in and they the same as the statistics before licensure.

The chart above (I love Excel!) graphically demonstrates two things. First, homebirth in Wisconsin with a direct entry midwife has triple the neonatal death rate of low risk hospital birth. Second, licensing midwives has made no difference in the death rate. That’s not surprising since a license is a legal document and confers no addition education or training. It merely stamps the imprimatur of the state of Wisconsin on a group of women who were undereducated and undertrained to begin with.

The website for the Big Push Campaign is very attractive and filled with information. There are numerous assertions that homebirth with a CPM is a safe option, but no statistics to support that claim. That’s not surprising when you consider that there are no national or state statistics exist that would support that claim. Even in Katie Prown’s own state, the data tell the same sad tale over and over again. Homebirth increases the risk of neonatal death, and, of course, that information must be kept from American women.

The Big Push Campaign is not about birth and it is obviously not about safety. It is about one and only one thing: money. Without a state license, CPMs cannot bill insurance companies or Medicaid. They must accept payment out of pocket and most women who choose homebirth cannot afford the thousands in fees that CPMs demand. But why should we license and pay a group of women who provide substandard care?

So I have a public question for Katie Prown, who was instrumental in gaining licensure for CPMs in Wisconsin, and who insisted that licensure would ensure the safety of homebirth in Wisconsin:

How can you tout the safety of homebirth when the statistics from your own state show that homebirth increases the risk of neonatal death?

As I wrote in I am a special snowflake, dammit!, Barbara Herrera, Navelgazing Midwife, has unintentionally displayed the self referential character of natural childbirth advocacy, She demonstrated an inability to treat other women respectfully and the rather bizarre belief that when women make different childbirth choices, they are judging her and her specialness.

In addition to illustrating the self referential nature of NCB advocacy, Herrera unintentionally revealed some astounding facts about natural childbirth advocates in general and homebirth (direct entry) midwives in particular. First, natural childbirth is not about babies, and it’s not about birth; it is all about them:

I absolutely acknowledge the near-obsession with birth some of us have… the birth junky-ness of us. But, don’t *most* people have *something* that drives them? That is a place in their lives that creates a great deal of pleasure, whether doing or listening?

Second, for natural childbirth advocates and general, and homebirth midwives in particular, birth is their hobby!

For some, it’s collecting trains… others, talking about airplanes… and still others, it’s religion that’s the obsession. Might we not acknowledge that for some people (people like me!) that obsessive/constant/overwhelming passion has been and is birth? That if we *have* that drive within us, it isn’t *wrong*, but just different?

Well that explains a lot, doesn’t it? According to Dictionary.com, a hobby is:

an activity or interest pursued for pleasure or relaxation and not as a main occupation

For homebirth midwives, attending births is an activity pursued for pleasure and not an occupation. Since it’s a hobby, they see no reason to get bogged down with years of college and hours of in hospital training. A certification program is enough. After all, where’s the pleasure and relaxation in studying hard or learning about the prevention, diagnosis and management of complications when all you really want to do is catch babies?

It’s kinda like fishing. Fishing is an interest pursued for pleasure or relaxation. There’s no reason to get a degree in veterinary medicine just to catch a few fish, right? Why get a degree in midwifery (a real, college degree) just to catch a few babies?

Here’s the problem: birth is serious and women giving birth deserved to be cared for by professionals. That’s because birth, unlike fishing, has a very real potential to end in the death of the baby or mother. It’s not about, nor should it be about a birth junky getting her fix. Homebirth (direct entry) midwives do all midwives a disservice by pretending that birth is a hobby. Midwifery is a profession, not an opportunity for voyeurism.

Interestingly, the less training a homebirth midwife has, the more likely she is to refer to herself as a “granny midwife,” but that’s an insult to the real granny midwives of yore. Those women were not indulging their personal passion; they were providing medical care to the best of their ability. They attended births to prevent death, not to get their birth junky fix. They administered herbs because those were the best medicines they had at the time, not because they were “natural.” They delivered breech babies vaginally (and lost quite a few) because they had no other choice, not because they were “respecting the process.” They lamented their limitations, and tried to extend their knowledge; they didn’t glory in ignorance and pretend that knowledge was not worth the effort expended to learn it.

Herrera inadvertently spoke the truth. Direct entry midwifery should be abolished because is nothing more than a hobby for women who love watching other women’s births. They refuse to acquire real training because they are too lazy, and can’t see the point if all they want to do it catch a few babies. Direct entry midwifery is by, about and for midwives. Patients exist merely to provide the fix.

Direct entry midwifery is an insult to midwifery and to women. Midwifery, real midwifery, is about the needs of the mother and baby, not the needs of the midwife. It’s about providing safe care, anticipating emergencies and treating complications. It’s not about pretending that birth is safe, insisting that emergencies never occur and imagining that complications can be treated by dialing 911.

American women and babies deserve real midwives, not hobbyists.