Natural childbirth advocates profess puzzlement that the promotion of their personal preferences as “normal” birth is disrespectful to women who make different choices. To help them understand why their rhetoric is hurtful, hateful and utterly self referential, I offer a thought experiment. Let’s apply the Lamaze philosophy on “normal” birth to sex.

Below is a paraphrase of the Lamaze position paper, Promoting, Supporting, and Protecting Normal Birth. Natural childbirth advocates: do you see the parallels and why the insistence that your personal preferences represent nature’s ideal is so distasteful?

Promoting, Supporting, and Protecting Normal Sex
by The Institute for Safe and Healthy Sex

Sex in the 21st century is characterized by choices and practices directly antithetical to normal, natural and physiologic processes. Nature designed sex to occur only between one man and one woman, within the context of a permanent pair-bonded relationship, and always leading to pregnancy. In contrast to what we know about the physiologic process of sex, society now countenances homosexual relationships, sex outside of marriage or even outside of a relationship and artificial contraception. These practices are alarming because there is no research demonstrating that choices like homosexuality, oral sex and contraception respect and facilitate normal physiology.

The normal, natural, physiologic process of sex involves a sequence of interacting events: the male erection, vaginal lubrication, ejaculation, etc. It is exquisitely orchestrated by male and female hormones and facilitated by the missionary position. Restriction to the missionary position helps men and women tolerate increasing levels of oxytocin (the love hormone), and this ultimately ensures not only that sex will progress, but they will benefit from the release of endorphins, nature’s narcotic.

The Institute for Safe and Healthy Sex encourages men and women to be confident in their ability to have heterosexual sexual intercourse. The Institute further encourages health-care providers and policy makers to understand and trust the normal, natural process of heterosexual intercourse and to promote, support, and protect men’s and women’s confidence and their ability to have heterosexual intercourse without the unnatural distractions of abnormal sexual practices or artificial contraception.

The Institute of Safe and Healthy Sex has identified six care practices, that promote, support, and protect normal heterosexual intercourse:

Practice #1: All men and women must recognize and acknowledge that Nature designed sex to occur only between one man and one woman.

Practice #2: Sex should be restricted to only heterosexual, monogamous, long term relationships (ideally marriage), because that is the only physiologic situation.

Practice #3: No artificial interference with fertility.

Practice #4: All sex should have to potential for conception. Accordingly, there should be no homosexual sex and no oral or anal sex.

Practice #5: Sex should be restricted to the missionary position because it affords the best possibility for conception, which is what Nature intended.

Practice #6: There should be no artificial components to heterosexual intercourse. Synthetic lubricants, vibrators and sex toys interfere with the physiologic sex that nature intended.

The goal of the Institute for Safe and Healthy Sex preparation for sex is that men and women have confidence in their inherent ability to have normal, heterosexual intercourse. In Institute for Safe and Healthy Sex sex education classes, men and women learn to understand and trust normal, natural, physiologic sex and avoid homosexual tendencies, non-normal sexual practices, and artificial contraception. The Institute for Safe and Healthy Sex encourages all men and women to attend sex education classes that promote the six care practices described above and that increase their confidence in their ability to have sex normally.

The mission of the Institute of Safe and Healthy Sex the is to promote, support, and protect normal sex through education and advocacy. The Institute for Safe and Healthy Sex was launched to support initiatives that provide credible, relevant, and useful information about normal sex to young men and women and to advance the agenda of promoting, supporting and protecting normal sex.

Have you heard the joke about the man who refused help during a flood?

There was a huge flood in a village. One man said to everyone as they evacuated, “I’ll stay! God will save me!”

The flood got higher and a boat came, and the man in it said “Come on mate, get in!” “No” replied the man. “God will save me!”

The flood got very high now and the man had to stand on the roof of his house. A helicopter soon came and the man offered him help. “No, God will save me!” he said.

Eventually the man drown. He got by the gates of heaven and he said to God, “Why didn’t you save me?”

God replied, “For goodness sake! I sent a boat and a helicopter. What more do you want!”

I was reminded of that joke when contemplating the musings of Shannon who is planning a home VBAC after 4 C-sections. Not surprisingly, Shannon is having a difficult time finding a homebirth midwife who will care for her. Indeed, several have already turned her down. But Shannon is sure “God [is] still wanting me to continue with a midwife.”

That’s a truly amazing coincidence when you think about it. Isn’t it great that God wants for Shannon exactly what she wants for herself!

I believe God designed our bodies and He designed our bodies to birth vaginally. There is a place for doctors when they are needed, but I do not believe pregnancy is an illness. I believe too many interventions are taking place by doctors and their staff that are creating an epidemic of c-section births. I also believe that one day they are going to answer to God for it.

It’s downright miraculous that God’s plan mirrors Shannon’s plan so well.

So why have homebirth midwives been turning down Shannon’s plan for a home VBA4C? Homebirth midwife Diana initially agreed to provide care, but:

About six weeks ago Diana had a VBAC client in labor that started screaming in pain and grabbing her incision site. With any VBAC client there is a risk of uterine rupture and they made the judgement call to transfer to the hospital, which resulted in an emergency c-section. The client did NOT have a rupture, but the fear of losing the mother or the baby was very traumatizing for the midwife.

Evidently it had occurred to Diana that a patient could sustain a uterine rupture at home and disaster might result. And then:

Fast forward a few weeks as the wait was on for the birth of Diana’s precious grandbaby. Finally, the mother went into labor on November 30th, but it ended in tragedy. The baby was stillborn. Horrifying!

At this point Diana declared that she could not participate in a VBA4C, but she did offer Shannon names of other local homebirth midwives. Unfortunately, on the exact same day that Diana’s grandbaby died:

one of Diana’s fellow midwives had attended a funeral for baby that was the result of a uterine rupture.

She wasn’t interested in attending a home VBA4C, either. Along came Sallie:

Much to my surprise she said she would take my case. She even told me a story about a birth she attended of someone who had a VBA4C in which the baby was over 11 pounds to encourage me that it can be done. So, Sallie will be my new midwife.

But here’s the best part:

[Sallie] wants to take Diana to lunch and try to be an encouragement to here during this traumatic time. Also, there are always two midwives present at a birth nd she wants to see if Diana will be the second midwife in my case. I just love the compassion that midwives have for their patients and fellow midwives.

So God sent Shannon a boat and a helicopter, but she’d rather take her chances with Sallie.

I guess the prophet Jeremiah was right when he said: There are none so blind as those who will not see.

Barbara Herrera, Navelgazing Midwife, is mad. Ostensibly, she’s mad about the ripping apart of natural birth, but even a cursory examination of her post reveals that she’s really mad about being denied special status because of unmedicated childbirth. She and her philosophical compatriots who gave birth through the vagina without pain medication are special snowflakes, dammit, and how dare anyone question that specialness?

Barbara starts in on Gina Telling who implores “Don’t judge me because I had a C-section.” That sounds rather uncontroversial, but not when you consider that judging other women is half the fun of being a special snowflake. Herrera gives NO consideration to Telling’s plea. Instead, she attempts to justify the judging with a rather startling example of projection:

Women healing from birth trauma often find the telling and re-telling of their stories an integral part on their paths to normalcy (not the old normal, but the new normal). But those around them seem to hit a saturation point and it is a rare woman who has not heard, “Can’t you just get on with your life already?”

There are other topics that make people uncomfortable… death and illness are two of the most common… but I find anger, pain and disappointment about a woman’s own birth experience all but taboo…

Those women who berate Telling are really not berating her. They need to work through their trauma at their own tragically imperfect birth experiences, by informing Telling of what was wrong with hers. And what if Telling does not want to be a foil for other women’s self exploration? She must be uncomfortable with the pain and disappointment of other women. Huh? When did Telling’s birth experience become the property of other women to use for their own needs?

Another article leads Herrera to make her self concern explicit. She is mad, mad, mad about “Looks Like Nobody Ever Had a Baby Before” by Daphne Caruana Galizia. Ms. Caruana Galizia, mother of two (born with midwives, no less) dares to suggest that having a baby is not an achievement:

“Imagine just how much less angst there would be if the breathing trainer, or whatever they’re called, were to say repeatedly: ‘Remember that trillions of women have had babies throughout history, and that you’re doing nothing special. Even if it feels like you’re the only woman in the world to give birth, you’re not.'”

Oh, the horror. Ms. Caruana Galizia must be deeply dysfunctional. According to Herrera:

… Did she not feel special having her baby? Unique? How does that not happen? How can a woman who’s, in a sense, birthing “God”, not feel amazingly gifted/special/unique?

How sad for her that she is a special snowflake and does not even realize it. Suddenly Herrera has an insight:

But, if I think about it longer, maybe she doesn’t feel that birth-breastfeeding is that important after all. Isn’t that the implication …? That we’re navelgazingly obsessed with our biological performances?

Ya think?

Herrera concludes with the all out self-referential, self-pitying claptrap that characterizies NCB:

Those of us that write need to get louder, more aggressive in our countering articles such as those mentioned above. I challenge natural birth-oriented bloggers (myself, included!) to attack these overt slams against our birthing choices word for word.

So let me get this straight. Two women write articles about their own feelings and Herrera thinks this is all about her choices? Two women write that they don’t want to be assaulted with the self-congratulatory posturing of NCB advocates and Herrera thinks the appropriate response is to yell into their faces even louder?

I guess it’s not all that surprising. Herrera and her friends are special snowflakes, dammit, and the whole world should be forced to acknowledge it.

Australian midwife and homebirth advocate Lisa Barrett has lost her bid to avoid an inquest into the birth and death of a baby who died under her care.

Barrett claimed that the death of Tate Spencer-Koch should not be investigated because a baby who dies before birth is not legally a person. In other words, because Barrett was so inept at resolving the shoulder dystocia (40 minutes until delivery of the shoulders) that the baby died before the entire body was born. And because she was incapable of saving the life of an otherwise healthy baby, as opposed to merely rendering it brain damaged, she should escape investigation.

But the ambulance crew, which arrived several minutes after the baby’s birth, pointed out that Tate was alive at the time of birth. Although she had no heartbeat, an EKG revealed electrical activity of her heart (pulseless electrical activity or PEA), the last stage before death. If she had electrical activity when they arrived, she was surely alive at the time of birth.

Barrett countered that electrical activity of the heart should be ignored since it was not mentioned at the time that the definition of a “person” under Australian law was issued in the 1800’s. That definition required independent breathing on the part of the baby. Barrett thought she had found a way to avoid an inquest by invoking a technicality and appealed to the Australian Supreme Court.

The Court rejected Barrett’s argument. The opinion came down yesterday.

In a unanimous decision, the Full Court today rejected a midwife’s application for a judicial review of a decision by Deputy Coroner Anthony Schapel.

Lisa Barrett claimed Mr Schapel had exceeded his jurisdiction by conducting an inquest into the July 2007 death of newborn Tate Spencer-Koch…

Common law dating back 130 years holds that only babies who breathe independently of their mothers are “born alive” and have legal rights.

However, Mr Schapel ruled a weak, electrical rhythm in Tate’s heart was a sign of life and held an inquest…

Ms Barrett asked the Full Court to overturn that decision, saying rhythms were only “a precursor to life”.

Today, Justice Richard White disagreed.

He said a NSW decision held the “born alive” rule was based on “anachronistic and antiquated factors” and “primitive” medical knowledge.

“It would be incongruous, to my mind, that the presence of a bodily activity indicating a successful resuscitation may be possible … should nevertheless be disregarded as a sign of life,” he said.

“The Coroner’s Court is not confined only to the kinds of evidence available to the courts in the 18th or 19th Centuries.”

The investigation will now proceed and Barrett is right to be concerned that she may be found guilty of malpractice. Moreover, the case has implications beyond the malpractice of a specific midwife.

Attorney-General John Rau said the inquest would significantly impact regulation of the homebirths industry.

“One of the questions no doubt the Corner will have to consider is had this delivery been managed in a medical setting, whether the child would have been in any way compromised let alone died,” he said…

“It shines a bit of light on an area that’s been of concern for quite some time.”

No wonder Barrett has made such strenuous efforts to avoid investigation.

Lots of women read this blog for lots of different reasons.

There are some who have learned in the hardest way possible that homebirth and “natural” childbirth advocates have no idea what they are talking about. There are true believers who post to demonstrate their (pseudo-)knowledge. There are women who came to the site prepared to “teach” me about homebirth and “natural” childbirth and instead found themselves learning information that changed everything. And, of course, there are loyal readers who are distressed by the spread of pseudoscientific nonsense and wish to discuss the scientific facts.

I have a question for all my readers, or rather a question with many variations, each directed toward a specific group.

To those who suffered a tragedy and thereby learned that most of what they thought they “knew” about childbirth was not true:

Is there anything that I could have told you beforehand that might have swayed you from your belief in homebirth and natural childbirth?

To those who are still true believers:

What information could I supply to you to help you realize that the foundations of homebirth and natural childbirth advocacy are pseudoscience and that most of it is directly contradicted by copious existing scientific research?

To those who changed their minds after reading the posts and engaging with me and other commenters:

What made you realize that what you had been told by homebirth and natural childbirth advocates was not true?

To those who already know that science does not support most of the claims of homebirth and natural childbirth advocates:

What do you think we should say, and what information should we offer, to open the eyes of homebirth and natural childbirth advocates who have no idea that most of what they believe is factually false?

I, of course, have some thoughts on the answer. It seems to me that there are three particularly powerful arguments that seem to resonate most with homebirth and natural childbirth advocates:

1. The Midwives Alliance of North America (MANA) is hiding their own safety data.

As the old adage goes, “it’s not the crime, but the cover up.” Paradoxically, what appears to be the most damning fact is not that homebirth has been shown, in every scientific study and existing state and national statistics, to triple the rate of neonatal death, but that MANA refuses to release their own statistics on the neonatal death rate of homebirth midwives. Even the most committed homebirth and natural childbirth advocates know that MANA would be shouting good results from the rooftops and that their strenuous efforts to withhold the neonatal death rates from the more than 18,000 certified midwife homebirth is a virtual admission that homebirth increases the neonatal death rate.

2. American homebirth midwives do not meet the licensing requirements for ANY first world country.

The first surprise for committed homebirth and natural childbirth advocates is realizing that there are TWO types of midwife in the US. Homebirth midwives have done their utmost to confuse women on this point, changing their name from direct entry midwives (DEMs) to certified professional midwives (CPMs) so as to be nearly indistinguishable from certified nurse midwives (CNMs). The second surprise is learning that American homebirth midwives are considered undereducated and undertrained by all other first world countries and would be ineligible for licensure in the UK, the Netherlands, Canada and Australia.

3. Childbirth is and has always been, in every time, place and culture, one of the leading causes of death of young women, and the day of birth is the single most dangerous day in the entire 18 years of childhood.

Homebirth and natural childbirth advocates think childbirth is inherently safe because the current rates of neonatal and maternal mortality are quite low. They don’t realize that this is product of modern obstetrics. They are often shocked to learn that in the past 100 years, modern obstetrics has lowered neonatal mortality by 90% and maternal mortality by 99%. Impressive as these figures are, however, the statistic that seems to have the most impact is one that most women know but did not consider: the natural miscarriage rate is 20%. Obviously, pregnancy is not inherently safe since such a large proportion of pregnancies end in the death of the embryo. Once that is acknowledged, it is hardly an intellectual leap to accept that childbirth in nature has very high rates of neonatal and maternal mortality.

These are just my impressions, of course. That’s why I’m asking you my readers. What would make homebirth and natural childbirth advocates realize, once and for all, that most of what they think they “know” isn’t even true?

Do political threats influence the way we view medical threats? That’s the conjecture of those who claim that the primary political threats of a generation define the identity of the medical threats that command the attention of the general public. According to the theory, the primary political threat of the early 20th Century was war, an attack on the self by others, and the medical threat that captured our attention was infectious disease, an attack on the body by external pathogens. In the late 20th Century we were preoccupied by the threat of internal dissension, fear of Communist spies and others of insufficient loyalty undermining the country from within. Cancer became our medical preoccupation, a disease of internal betrayal.

What is the political preoccupation of the early 21st Century and how does it affect our medical preoccupations? I would argue that Americans perceive the primary political threat to be terrorism, an insidious, uncontrollable threat, launched by others for their own purposes. Our medical preoccupation, not surprisingly, is the threat of environmental “toxins.”

I wrote about our preoccupation with toxins last year:

They are invisible, but all around us. They constantly threaten people, often people who unaware of their very existence… [I]t is axiomatic that they have be released into our environment by “evil” corporations.

Like many other purveyors of alternative health quackery, vaccine rejectionists are obsessed with the notion that they are secretly being poisoned by big corporations. In other words, vaccination is feared as corporate terrorism.

Consider why terrorism inspires so much fear. Terrorism is a catastrophe caused by deliberate action of others as opposed to mere chance. Although a person is far more likely to be killed by an auto accident than by terrorism, people routinely dismiss that risk by adopting an attitude of fatalism. Since accidents are supposedly random there’s no point in worrying about them.

Terrorists can concoct their nefarious plans while living unrecognized among us. As a society we have become obsessed with terrorists “threats” that are presumed to be invisible yet always among us. We have adopted an ever growing list of measures to prevent terrorism, most of which are largely ineffective (airport screening) and some of which are down right ludicrous (inspection of car trunks before being allowed into parking garages).

In a curious way, terrorism is viewed as a technological threat, while random causes of death (even if they involve technology) are viewed as “natural” and therefore better. Terrorism often takes the form of exploding devices, ranging in sophistication from those that spread shrapnel, to those that spread deadly chemicals to the ultimate threat of “dirty bombs” that spread radiation. You are every bit as dead if you fall into the ocean and drown, but people do not spend a lot of time worrying about being a victim of drowning even though it is far more likely than being a victim of terrorism.

Fear of vaccination mirrors the fear of terrorism. Vaccine injury is the product of a deliberate action (receiving the vaccine) as opposed to injury from the infectious agent itself. Although the odds of dying from a vaccine preventable illness are approximately 1,000 times higher than the odds of dying from the vaccine, vaccine rejectionists routinely ignore that risk by adopting an attitude of fatalism. Since diseases are supposedly random, there’s no point in worrying about them.

Perhaps the scariest thing for vaccine rejectionists is the notion that vaccinations contain unrecognized threats that are free to circulate among us because of government mandated vaccination. Vaccines are viewed as a form of corporate “terrorism”, where unsuspecting individuals are unwittingly poisoned by being tricked into accepting vaccination for their own “good.” Because we don’t recognize the threat, we cannot protect ourselves against the threat.

Finally, vaccines represent technology (difficult to understand technology, no less) and diseases are “natural.” There are vaccine rejectionists who proclaim with a straight face that it is better to acquire “natural” immunity to an infectious disease by actually contracting the disease than to acquire purportedly unnatural immunity through vaccination. Of course acquiring “natural” immunity requires that you survive the infectious disease, a critical fact often overlooked by vaccine rejectionists.

Obviously the analogy between political fears and medical fears is imperfect, but it is worth pondering whether the fears of vaccine rejectionists are shaped by current political preoccupations. At the very least, it may suggest new avenues for public health education, combining basic education in immunology and science with careful attention to the unarticulated fears of vaccine rejectionists.

How do homebirth midwives handle mistakes? They bury them, of course.

They literally bury the babies who die under their care in achingly tiny white coffins. But that isn’t enough. They completely obliterate their existence by refusing to report the neonatal death rates at homebirth.

Finally, an official body has noted that homebirth midwives, organized as Midwives Alliance of North America (MANA), have refused to release their own data on babies who have died at homebirth.

The state of Oregon is currently considering enlarging the scope of practice of direct entry midwives. This is occurring despite the fact that there is no data demonstrating that direct entry midwives are safe practitioners with the limitations currently in place. Apparently, when this data was sought, some midwifery advocates suggested relying on the safety data collected by MANA over the past decade, which, remains hidden. The hearing officer pointedly noted MANA’s conflict of interest (Summary of Public Hearing Testimony and Written Comments, With Recommendations of Hearings Offucer: October 28, 2010).

… [T]he Hearings Officers has reservations about the Agency relying on the Midwives Alliance of North America (MANA), a private organization with a stated goal of promoting midwifery, with the task of receiving, reviewing, archiving, and disseminating data…

From the legal perspective, the Hearings Officer also has concerns that having the State rely upon a private organization to archive data could run afoul of the State’s public records laws…

In addition, though the report does not mention it, the Director of the state’s Board of Midwifery is Melissa Cheyney, the same person who is hiding the MANA data (Homebirth midwife Melissa Cheyney has a conflict of interest).

The hearing officer also notes that MANA has withheld its data from the public, put insurmountable barriers in the way of researchers attempting to gain access to the data, and has insisted that the data could be used only in ways in which MANA approves.

… MANA appears to make data available to researchers in the context of an application and payment of an application fee. The application process appears to rely on committees which examine the structure and nature of the proposed research. In addition, persons desiring access to data must agree to agree to conduct their study in accordance with a Community-Based Participatory Research model in which MANA would be entitled to have a participatory role in the research. MANA also charges a fee of $250 for individuals and $1000 to institutions for access to the data base…

It’s not really surprisingly that MANA is withholding their data. Colorado licensed midwives are required to submit their outcome data directly to the state and the death rate is appalling (Inexcusable homebirth death toll in Colorado keeps rising).

… In 2009 Colorado licensed midwives provided care for 799 women. Nine (9) babies died for a homebirth death rate of 11.3/1000! That is nearly double the perinatal death rate of 6.3/1000 for the entire state (including all pregnancy complications and premature births).

The data is conveniently broken down by type of death and place of death. For example, there were three intrapartum deaths for an intrapartum death rate of 3.8/1000, more than ten times higher than the intrapartum death rate commonly experienced in hospitals. There were 4 neonatal deaths for a neonatal death rate of 5/1000. That’s ten times higher than the national neonatal mortality rate for low risk hospital birth with a CNM (certified nurse midwife)…

And the homebirth death toll in Oregon will include stories like this one reported in the Register Guardian:

The call to paramedics came at 8:10 p.m., the instant midwife Anita Rojas realized the head of the breech baby she was delivering was stuck.

Twenty-one-year-old Kelsie Koberstein was swept up by medics in a blur of pain and fear.

Rojas rode in the front of the ambulance, with Koberstein’s mother and best friend rushing behind in their car…

On her back, her legs pushed up as high as they could go, she clutched the hand of a paramedic as if he were her only anchor to reality…

At Sacred Heart Medical Center, the on-call emergency room obstetrician-gynecologists, Drs. Elizabeth McCorkle and Brant Cooper, wasted no time.

As they instructed paramedics over the hospital radio, they learned this birth was going to be as difficult as they come: It wasn’t just a breech birth, but a “footling” – where a foot emerges first.

Just a few centimeters in width, a tiny foot might not open the cervix wide enough to allow the baby’s head and umbilical cord to pass through. If the head becomes trapped, the baby could quickly suffocate.

When medics pulled up to the doors, the doctors leapt into the back, refusing to squander precious seconds bringing Koberstein inside. The doctors had to turn Lucian’s head 180 degrees in order to free him, a move that took at least 20 minutes.

By then it was too late.

The infant was dead.

It’s about time that those charged with regulating direct entry midwifery have noted that homebirth midwives are hiding their own safety statistics. It doesn’t take a rocket scientist to imagine that MANA’s own data shows that homebirth with direct entry midwife dramatically increases the risk of neonatal death. Now it is time that those charged with regulating direct entry midwifery demand that MANA hand over that data. It is always possible that, as detailed in the report, MANA may manipulate the data in ways that will hide the true dangers, but at least the data itself will be a start in the right direction.

The latest edition of the journal Obstetrics and Gynecology contains a commentary destined to make a splash: Electronic Fetal Monitoring as a Public Health Screening Program; The Arithmetic of Failure by Drs. David Grimes and Jeffrey Piepert. The article makes a bold claim:

Electronic fetal monitoring has failed as a public health screening program… Because of low-prevalence target conditions and mediocre validity, the positive predictive value of electronic fetal monitoring for fetal death in labor or cerebral palsy is near zero. Stated alternatively, almost every positive test result is wrong…

It is critical to note that the authors are not claiming that fetal monitoring is a failure, merely that electronic fetal monitoring fails to provide additional benefits over monitoring by intermittently listening to the fetal heart rate. The authors provide a breathless analysis of the causes for this purported failure, implying that basic statistical analysis made this failure easily predictable.

In my judgment, the authors commit two serious, and inexplicable, errors.

1. Although, the authors provide a detailed statistical analysis of the limited ability of electronic fetal monitoring (EFM) to detect fetal death (stillbirth), such an analysis utterly misses the point. The purpose of electronic fetal monitoring is not to detect fetal death, but to prevent it. The primary purpose of fetal monitoring (whether by auscultation or electronic) is to diagnose fetal distress in progress, not to diagnose death, the end point of severe fetal distress. Curiously, the authors give short shrift to this. And since the authors virtually ignore the primary purpose of the test, their analysis, while sure to garner headlines, is not particularly compelling.

2. The authors complain that screening for rare events leads to tests with poor predictive value. Fortunately, adverse outcomes in labor are relatively rare. That’s why neonatal deaths are expressed per 1,000 births. Therefore, it is not a surprise that screening for poor fetal outcomes has a poor predictive value. But if are goal is to prevent rare events, that is virtually inevitable.

The authors explain the nature of screening tests and the measurements that determine the validity of a screening test, including positive predictive value, negative predictive value and the impact of prevalence. I performed a similar analysis in a post written 2 years ago (Sensitivity, specificity and fetal monitoring). I used round numbers to illustrate the concept and it may helpful to read my post before reading the actual paper.

The key finding of the Grimes, Piepert paper is this:

Here, electronic fetal monitoring is assumed to have a sensitivity of 57% and specificity of 69%,7 and the prevalence of fetal death is low: 50 per 100,000… [T]he predictive value of a positive electronic fetal monitoring screen [is] 29/31,013, which rounds off to zero percent. Because of poor test specificity, more than 30,000 false-positive tests … overwhelm fewer than 30 true-positive results … Given a worrisome tracing, the probability of fetal death is, rounded to percent, nil.

In other words, if EFM is used to predict which babies will definitely die, only 1/1000 will actually die. That seems compelling until you consider that EFM is not used to identify babies who will definitely die, it is used to identify babies who are not getting enough oxygen and therefore may suffer permanent brain damage or die. As the authors briefly acknowledge in what is virtually an aside, EFM performs very differently in that situation.

More common but less serious, fetal acidemia at birth [as a result of low oxygen in labor] may provide the most charitable assessment of electronic fetal monitoring. In a large randomized controlled trial with a frequency of fetal acidemia at birth (umbilical cord artery pH less than 7.15) of 10%, nonreassuring fetal heart rate patterns had a positive predictive value of 37%.13 Even for this common outcome, most positive tests were wrong.

Yes, the majority of babies identified as suffering from oxygen deprivation turn out to be fine, but 37 out of 100 (more than 1/3) are suffering from oxygen deprivation so severe that it may result in brain damage or death. That’s a number too large to ignore.

For perspective, it helps to consider a real world example, like mammography. The positive predictive value of mammograms is low. Most abnormal findings on mammography turn out to be benign. The positive predictive value for screening mammography in detecting breast cancer is in the range of 10%, considerably less that the PPV for electronic fetal monitoring in detecting oxygen deprivation (37%).

Moreover, routine mammographic screening of women under 50 saves only 1 life per 1400 women screened. That’s a PPV for preventing death of 0.07%, nearly zero using the methodology that Grimes and Piepert applied to EFM. Nonetheless, the recent recommendation to suspend routine screening of women under 50 met with a firestorm of protest.

The bottom line is that obstetricians are well aware of the serious limitations of electronic fetal monitoring. For every neonatal life saved, for every case of brain damage averted, hundreds if not thousands of monitoring strips falsely predict fetal oxygen deprivation. The issue is not whether fetal monitoring is a good screening test; everyone knows that it is a bad screening test. The problem is that there is no screening test that’s better.

The question we face is not whether EFM is highly effective, the question is whether EFM is worth it. That’s an ethical issue, not an arithmetic one.

On the surface, the old idea of the “refrigerator mother” causing autism and the new quack idea of vaccines causing autism might appear to have little in common. However, as Dr. Michael Fitzpatrick notes, they both rest on the same deeply flawed belief: it is the mother (through her emotional response or her actions) who causes autism in her child and it is the mother (through her emotional response or her actions) who has the power to prevent autism.

Fitzpatrick is the author of Defeating Autism: A Damaging Delusion, a physician and the parent of an autistic child. He writes bitingly about the quackery in the “crusade against autism.” Jenny McCarthy is an obvious target:

In the foreword to Louder Than Words: A Mother’s Journey Into Healing Autism, Jenny McCarthy is described as the ‘polar opposite’ of the ‘refrigerator mom’, the quasi-demonic figure blamed by a generation of postwar American psychotherapists for causing autism.

Yet the concept of the ‘warrior mom’, as McCarthy presents herself in her latest book, is not so much the polar opposite of the ‘refrigerator mother’ as a distorted mirror image. The ‘warrior mom’ is yet another reflection of the culture of mother-blaming and a manifestation of the burden of guilt carried by parents as a result of the influence of pseudoscientific speculations about the causes of autism.

Fitzpatrick elaborates:

The ‘refrigerator mother’ and the ‘warrior mom’ are linked through the decades by feelings of guilt, anger and blame. In Mother Warriors, McCarthy tells of a cathartic moment when her therapist tells her that ‘you have never dealt with the fact that you feel guilty for Evan’s autism’… When the guilt subsides, the rage takes over. Drying her tears, as she puts it, ‘I decided I had to go and kick some ass in the paediatric world’. Blaming themselves, blaming their doctors, blaming the world, ‘warrior moms’ carry the burden of both causing and curing their children’s autism.

The idea that mother’s are responsible for causing autism and curing it share important themes. First, it rests on the notion that the cause of autism is environmental and therefore easily modified. The role of genetics, which is almost certainly the primary cause of autism, is ignored:

Then it was toxic parents; today it is alleged environmental toxins (such as vaccines containing traces of mercury or MMR) to which parents have exposed their children. These theories also have the common features that they are entirely speculative and lacking in scientific support.

Second, autism, rather than being recognized as a feature of the child, is portrayed as something that attacks, hides or traps the “true” child.

… The Empty Fortress was the title of [psychotherapist Bruno] Bettelheim’s book and his characterisation of the imprisoned self of the autistic child (notoriously compared with a prisoner in a concentration camp) that had to be liberated through psychotherapy. ‘My son is trapped inside this label called autism, and I’m gonna get him out’, declares McCarthy in Mother Warriors…

The concept that autism is an intrinsic feature of the child is rejected for the more acceptable fantasy that autism is something that happened to the “real” child, and can therefore be prevented or reversed by simple modifications of the environment.

This fantasy dovetails nicely with the dominant contemporary mothering ideology that positions mothers as risk managers who “educate” themselves (about pregnancy, birth, vaccination, food, etc.) for the project of creating the perfect child. The child thus produced simultaneously reflects the mother’s competence, and advertises the mother’s superiority among her peers.

The autistic child, in many ways viewed by our society as the ultimate imperfect child, is a visible sign of parental failure. The desperation to avoid the stigma of this failure leaves mothers of autistic children particularly vulnerable to quacks and charlatans (like Jenny McCarthy) peddling pseudo-scientific theories of autism’s cause, its prevention and its treatment.

Autism almost certainly has a genetic basis and discovery of that basis should prove liberating for both autistic children and their mothers. Purveyors of the faulty idea of the “refrigerator mother” taught women to blame themselves for their children’s autism. Charlatans like Jenny McCarthy continue to encourage mothers of autistic children to blame themselves, not for their purported emotional frigidity, but for their purported negligence in failing to “educate” themselves about vaccination and failing to “protect” their children from vaccinations.

This mother-blame has got to stop. There are more than enough things for mothers to feel guilty about. Autism should not be one of them.

What do you do when no one will pay you the money that you want? You get your favorite Congresswomen to pass a law.

That’s what the homebirth midwives of America are trying to do; in collaboration with the MAMA Campaign (Mothers and Midwives in Action) Congresswoman Chellie Pingree plans to introduce a law forcing payment to substandard practitioners who insurance companies consider unqualified to provide medical care in childbirth.

So what if no one thinks their “skills” are valuable? Who cares if people don’t think they are a safe practitioners? They want money and dammit, others should be forced to pay. So much for the free market.

That’s the problem facing certified professional midwives (CPMs), member of a second, inferior class of midwife that exists nowhere else but in the US. They have less education and training than midwives in ANY first world county and would not be eligible for licensure in the UK, the Netherlands, Canada or Australia. Since they hare banned from hospitals as unqualified, they are restricted to attending homebirths. All the existing studies to date, as well as state and national statistics show that homebirth with an American homebirth midwife (as opposed to a certified nurse midwife) is the most dangerous form of planned birth in the US.

Actually, some people do want to pay them. A tiny percentage of women who think that homebirth with a high school graduate supervising is just dandy would be very happy to pay the thousands they think they deserve. One problem, though. Those patients don’t have the money. That’s why the large corporations who insure them must be pressured to pay for services that they don’t want, don’t trust, and don’t consider safe.

Birth junkies unite! Why should you be forced to get a college degree? That’s too hard. Why bother to learn about pregnancy complications? That’s too much of a downer. Just get together, give yourself a pretend degree and start collecting cash. Oh, wait. You already did that. You called the degree the CPM (to deliberately create confusion with the real degree, the CNM). But alas, no one wants to pay you to be a birth voyeur.

Enter Congresswoman Chellie Pingree and the MAMA Campaign. MAMA is supposed to stand for Mothers and Midwives in Action. The name is misleading on its face since it is sponsored by homebirth midwives with nary a mother in sight. According to their website:

Midwives & Mothers in Action, or MAMA, is a collaborative effort by the National Association of Certified Professional Midwives (NACPM), Midwives Alliance of North America (MANA), Citizens for Midwifery (CfM), International Center for Traditional Childbearing (ICTC), North American Registry of Midwives (NARM), and the Midwifery Education Accreditation Council

MANA, NACPM, NARM and MEAC and ICTC are organizations by and for homebirth midwives; indeed, MANA, NARM and MEAC are just branches of the same organization, Ina May Gaskin’s self created empire. Citizens for Midwifery is arguably the only organization among the 6 that is composed of mothers, but its only purpose is to promote homebirth midwifery. A more accurate name for the MAMA Campaign would reflect who runs it and why. That’s why I propose Midwives Angling for Money Again (MAMA), since that is its real purpose.

What is a CPM anyway? The CPM is a second, inferior class of midwife that exists in addition to the more highly trained nurse midwife CNM. In all other first world countries, a midwife has a four year university degree that includes in-hospital training. Certified nurse midwives in the US have a nursing degree and a master’s degree in midwifery. CPMs in contrast have a post high school certificate with no in-hospital training in preventing, diagnosing and managing childbirth complications. Real midwifery training was simply too hard, so a group got together and created a pretend credential to fool unsuspecting pregnant women. And who created that credential? MANA, NARM, MEAC and CfM, of course.

The MAMA Campaign claims to be:

Advocating for CPMs as a high-value option for quality cost effective maternity care.

Curiously, the slogan does not mention the safety of CPM care. That’s probably because every study done to date (even those that claim to show that homebirth with a CPM is safe) and state and national statistics show that homebirth with a CPM triples the neonatal mortality rate. Indeed, homebirth with an American homebirth midwife is the most dangerous form of planned birth in the US (See Homebirth kills babies, Homebirth with a direct entry midwife is th most dangerous form of planned birth, and Inexcusable homebirth death toll in Colorado keeps rising).

And it’s not clear that certified professional midwives provide care that is either high value or cost effective. Indeed, Canada, which used to have a similar class of midwives, has banned them from practice. Now all midwives in Canada must have a four year university degree.

Ironically if CPM care were safe, high value or cost effective, the insurance companies would probably be first on the bandwagon to pay CPMs and promote their use over the more highly trained (and more highly compensated) certified nurse midwives. Yet most insurance companies do not accept the CPM credential. The cost for a CPM attended delivery may be cheaper, but when you add the cost for hospital transfers, NICU stays, and handicapped infants suffering brain damage from lack of oxygen in childbirth, it no longer seems like a cost effective alternative.

The bottom line is simple. If you want to practice midwifery, you should be required to have a real midwifery education and real midwifery training, comparable to that anywhere else in the first world. If that’s too hard, you can award yourself a pretend credential (the CPM), but don’t expect the rest of us to pay you to live out your fantasy. The law promoted by the MAMA Campaign is nothing more than a special interest lobbying effort. It exists for one reason, and one reason only, to force insurers to pay practitioners who are undereducated, undertrained and unsafe: Midwives Angling for Money Again (MAMA).