Imagine if we did a study on triple bypass heart surgery and divided patients into three groups. The first group contains people who have no heart trouble and don’t have surgery. The second group contains people who have no heart trouble but have surgery anyway. The third group contains people who have unstable angina and undergo surgery. Guess which group would have the best health outcomes. Not surprisingly it would be the group who have no heart trouble and don’t undergo surgery. That’s because they were healthiest to begin with and were not exposed to the risks of surgery.

That’s pretty much the study that the World Health Organization did on C-section in Asia, Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007—08. They compared three groups: women who had no reason for C-section and underwent vaginal delivery, women who had no reason for C-section and had a C-section anyway (subdivided into antepartum and intrapartum C-sections), and women who had medical necessitating C-section and underwent a C-section (subdivided into antepartum and intrapartum C-sections). They also include a group for women who had operative vaginal delivery (forceps or vacuum) though they did not specify whether there were medical indication. It would hardly be surprising if the group that had no medical complications and underwent uneventful vaginal delivery would be the group with the best neonatal outcomes. And that would not be an indication that C-section was dangerous or inappropriate because we would expect that women experiencing complications would have higher rates of neonatal mortality.

What is surprising is what the WHO researchers actually found: the group of babies with the lowest neonatal mortality were born to women with NO reason to have a C-section but who had one anyway! In fact, the babies of women who had C-sections without a medical indication had the best results on every possible indicator.

For reasons that I cannot fathom, the World Health Organization is insisting that the interpretation of this study is simple:

To improve maternal and perinatal outcomes, caesarean section should be done only when there is a medical indication.

But that’s certainly not what the data on perinatal outcomes shows.

How about maternal outcomes?

Both blood transfusion and ICU admission were increased in the women who underwent C-section without medical indication, but the rate of hysterectomy was zero and the rate of maternal death was zero.

I don’t understand how the WHO researchers can justify their conclusions based on the data that they gathered. In fact, I’m not sure exactly what they thought they were studying. If we want to find out the safety and efficacy of a procedure (like C-section) we identify specific conditions or risk factors and divide patients into the treatment group (C-section) and the control group (vaginal delivery). We certainly don’t compare all women who had C-sections with all women who had vaginal deliveries because they are going to differ in very important ways.

I just don’t get it. This is a poorly designed study that can’t possibly yield any valid results. The authors compounded their error by misinterpreting (basically ignoring) the results that they got and instead reached a conclusion decrying C-section that seems to have been pre-determined before the study began.

Another homebirth death: horror, hemorrhaging and a crushing burden of guilt.

Yet another mother from the Homebirth board at Mothering.com has lost her baby in a homebirth tragedy. She has posted the entire story on her personal blog. In addition to the horror of her daughter’s death (with her other young children nearby) she is now coping with guilt. She writes movingly of her daughter’s birth:

…You are crowning. I support with my left hand, and cup your growing head with my right. So slippery, hot.wet… you drop into my hands like to heavy, wet blobs. You fall to the couch. I hear Faith yelling … “pick her up!”

I do, I pick you up … I look at your face. Blood is running from your nose. Your eyes are closed. No movement. Faith is sucking blood from your mouth with hers. She yells “get me my bulb syringe!” I try to wipe the blood from you nose, rub your back…

I sit down next to you, legs spread, you laying limp and white in between. They (Faith, Amy) are working on you. CPR, chest compressions (looks like the doll from CPR class two months before) …DeLee. I am sobbing, rubbing your feet. So long ago Faith called out, “someone call 911!”. such a limp foot… I touch the cord to see if it is pulsing. It is cold, collapsed…time has no meaning when a baby is silent.
.
CRY , baby, CRY! Sobbing..EMS flood the room, all around my baby…

Me, asking Faith, “Is there any way she could live?”

…………………………… “She’s not going to make it”

I know it’s true , baby, I know it. But, still they are working. They are taking you away from me, loading you up, headed for the children’s hospital.

I never see you warm again. They are loading me up. BLOOD everywhere, soaking, standing, staining….you were born in a river of blood, baby girl….

The baby was transported to a children’s hospital. The mother experienced a major postpartum hemorrhage and was transported to a different hospital.

Now the mother mourns:

I researched birth like a mad woman before all three of my homebirths. Every study I found said homebirth is safer for low risk woman than hospital birth. I truly never found anything to refute this.

I researched possible complications, researched choices for treatments for said complications. I timed my drive to the nearest hospital- 3 minutes…

But, the worst possible thing happened. what is considered a “true emergency” anywhere it happens, home hospital, birth center —- full placental abruption in labor. BUT…but…. if this emergency HAD happened in the hospital my baby would almost certainly be alive right now.

So, ultimately , my birth “choices” lead to my daughter’s death. that is where the beginning and end of the blame falls.

I am finding this weight of guilt to be crushing….

The comments on her blog, while meant to be comforting (particularly to the commentors, if not the mother) are inane. The most inane is this comment:

It’s such a short time, such a VERY short time, that anyone can live without oxygen. I’ve heard similar stories, ones that happen IN a hospital, and in most of the cases, they just can’t get the baby out in time. I don’t believe, even in a hospital setting, your outcome would have been different…

In other words, it’s just more of the same garbage that led the mother to make such a disastrous choice in the first place.

I’d like to offer a more honest appraisal:

To Aquila’s mother,

Do not blame yourself for your daughter’s death. Do not blame yourself for your choices, because you were never fully informed of the risks. If you would feel better placing blame somewhere, blame the homebirth advocates who, in books, lectures and websites, are fundamentally dishonest about the dangers of homebirth.

You would never have chosen homebirth is you had understood that this tragedy could happen. I know that you believe you “researched” homebirth, but unless you read the scientific literature, you merely researched disingenuous propaganda.

How do I know you read propaganda? You wrote, “Every study I found said homebirth is safer for low risk woman than hospital birth. I truly never found anything to refute this.” But did you ever read the actual studies? Did you ever read commentary on the studies by medical experts?

Were you aware that the leading American homebirth study (Johnson and Daviss, BMJ, 2005), DOESN’T show that homebirth is as safe as hospital birth? The authors compared homebirth in 2000 with hospital birth from a bunch of out of date papers. That’s because homebirth with a CPM in 2000 had nearly triple the neonatal death rate of low risk hospital birth in the same year.

Did you know that in the three years that according to CDC statistics, midwife attended planned homebirth is the most dangerous form of planned birth in the US? Did you know that those statistics show that homebirth with a homebirth midwife has triple the rate of neonatal death of low risk hospital birth?

I suspect that you didn’t know, because the sources that you consulted were silent on these points. And if you didn’t know, you couldn’t make an informed decision. Had you known the real risks and willingly accepted them, then you might consider accepting the blame as well. But you didn’t understand that this could happen, and if you didn’t understand, you are not to blame.

The latest mantra among “natural” childbirth advocates is informed consent. Advocates sigh and proclaim that they fully support women making the choice for interventions in childbirth, but fret that these same women cannot possibly provide a “truly informed” consent since they haven’t been appropriately informed.

Penny Simkin has produced a classic of this genre, Weighing the Pros and Cons of Epidural. Evidently there’s only one “pro”, relief of pain, and a long list of “cons,” nineteen in all. The list is a hodgepodge of minor “risks” (itching, shivering from cold liquid) and made up “risks” (feeling “detached,” decreased infant responsiveness). Presumably, Ms. Simkin believes that this long list of “cons” is required in order for a woman to give informed consent.

Simkin piously concludes:

The childbirth educator’s duty is to inform, not to talk women into or out of using an epidural. Many women will choose an epidural, when well informed of benefits, risks and alternatives; others will choose to avoid it if their labor allows.

Ms. Simkin and many other “natural” childbirth advocates are well aware that millions of women each year choose epidural for pain relief in labor, yet they are confident that women would make a different choice if they were fully informed.

Why does that sound familiar? Oh, I remember. That’s the same argument that the anti-choice forces make about abortion.

The anti-choice forces make the same pious argument in regard to abortion. Anti-choice advocates are well aware that more than a million women each year choose abortion, yet they are confident that women would make a different choice if they were fully informed.

According to the National Pro-Life Alliance:

Women’s “right to know” (informed consent) laws deal with this obvious conflict of interest by guaranteeing women receive critical information on the risks of abortion, such as infection, hemorrhage, danger to subsequent pregnancies, breast cancer, infertility, psychological consequences, and other dangers.

A Women’s Right to Know Act ensures that women are fully informed about adoption agencies, pregnancy care centers, medical assistance benefits, and the liability of the father to provide support.

It’s hardly surprising to find that their list of “cons” also contains a hodgepodge of “risks,” some utterly fabricated. The National Pro-Life Alliance has thoughtfully considered many, many things that women ought to know before choosing abortion:

* Thorough and accurate description of the nature of the proposed procedure.

* All physical and psychological risks involved in the abortion procedure versus carrying the pregnancy to term.

* A conflict of interest disclaimer disclosing what percentage of the clinic’s gross income is from abortion, as well as how much money the clinic stands to lose should she decide not to abort.

* Availability of adoption alternatives and financial help from the adoptive parents for prenatal care, childbirth, and neonatal care expenses.

* Medical assistance benefits that may be available for prenatal care, childbirth and neonatal care.

* Names and contact information for organizations that are willing to assist with the costs involved in carrying the pregnancy to term.

* Information on the liability of the father for child support…

At the time of each clinic consultation, a Women’s Right to Know law would also require that the mother be given relevant information about her unborn child and how the child would be affected by an abortion. This information would include:

* A sonogram of the unborn child.

* Probable gestational age of her unborn child, including provision of color photos of fetal development at 4-week increments.

* Description of the development of the child’s nerve endings and the child’s ability to feel pain at each stage of development.

* Relevant information on the potential survival of a child at its stage of development and the requirement of the doctor to take measures to save the life of the child should it be born alive.

Should we take the anti-choice forces at their word? Are they really interested in making sure women are informed about risks? The Guttmacher Institute, a pro-choice organization that provides information on reproductive health, doesn’t think so. In fact, they believe that anti-choice forces are really interested in “misinformed” consent:

Under the banner of informed consent, a majority of states have enacted abortion counseling laws requiring physicians to provide specified information to women seeking abortions. Many of these laws require the state health department to develop detailed written materials that must be distributed to women prior to the procedure.

An analysis of these state-developed materials demonstrates that they do not always measure up to the gold standard of informed consent. Particularly with regard to certain hot-button issues, the information presented is either out-of-date, biased or both. In some cases, the state goes so far as to include information that is patently inaccurate or incomplete, lending credence to the charge that states’ abortion counseling mandates are sometimes intended less to inform women about the abortion procedure than to discourage them from seeking abortions altogether. (my emphasis)

Anti-choice advocates do not hide their opposition to abortion, but they have learned that the majority of women do not share that opposition. They recognize that a frontal assault on abortion is doomed to failure. They have settled instead on undermining a woman’s right to choose by misinforming her about the “risks” and placing obstacles in her path under the guise of “informed consent.”

“Natural” childbirth advocates have enthusiastically followed the playbook of anti-choice activists. They recognize that the majority of women do not share their philosophical objection to pain relief in labor. They have acknowledged that a frontal assault on epidurals is doomed to failure. They have settled instead on undermining a women’s right to choose pain relief in labor by misinforming her of the “risks” and placing obstacles in her path under the guise of “informed consent.”

Such tactics are not merely disingenuous, they are unethical in regard to abortion, and they are unethical in regard to pain relief in labor.

I am horrifed by my most recent “award.” Not by the “award” itself; it’s the usual fact-free drivel that passes for humor among homebirth advocates:

I am very pleased to announce that the inaugural Wingnut Awards have been voted upon by JB [Joyous Birth] festival attendees, and that the following nominees have been successful in achieving the status of Wingnuttery…

The Wingnut Award for Online Contributions to the Homebirth Disinformation Campaign was awarded to Dr Amy. Congratulations Dr Amy! If anyone knows where we can send her certificate, please let us know!

… [C]ongratulations to the winners. Craptastic effort all round! Good thing there are still so many people happy to shoulder the burden of keeping women in our place or who knows what we might achieve?!

That’s your standard homebirth advocates’ charge against me, and, as usual, no one dares to site a specific instance of “disinformation” for fear that it will be shown that I am right and they are wrong.

No, I’m not horrified by the award; I’m horrified by the presenter, Janet Fraser, the leading Australian advocate of unassisted childbirth (stuntbirth). I’m distressed that any woman would consider sacrificing the life of her child for bragging rights, but I’m appalled that someone whose baby is actually dead as the result of her selfishness and self-absorption would go on being self-absorbed.

Janet Fraser, have you no shame? Your precious baby is dead and your refusal to seek prenatal care or assistance in birth is very likely to blame. And, amazingly, you are treating the entire subject as a big joke.

Fraser was interviewed in late March 2009, supposedly after labor with her third child had begun:

Janet Fraser is in labour… Has she called the hospital to let them know what’s happening? “When you go on a skiing trip, do you call the hospital to say, ‘I’m coming down the mountain, can you set aside a spot for me in the emergency room?’ I don’t think so,” says Fraser, whose breathing sounds strained.

This is pretty much where we end the conversation that started with me calling Fraser and asking if it was true that her organisation, Joyous Birth, was advocating that women go it alone giving birth at home, with no midwife or GP or bags of resuscitation gadgets.

“Free-birthing, plenty of women do it,” she says. In fact, Fraser is doing it right now. “I prefer to be an autonomous care-provider,” she says…

Janet Fraser’s son, 5, was planned as a home birth, but came into the world via an emergency caesarean after Fraser was transferred to hospital. Her daughter, 2, was born at home with a midwife attending.

Fraser is 40. She hasn’t seen a doctor or any health professional since becoming pregnant this time. No ultrasound, no genetic testing, no internal examinations, no stethoscope. Does she have any feeling for how long the labour will go? “I could do this for days. My daughter’s birth was 50-something hours. You just do it — it’s just birth, a normal physiological process.”

And death in childbirth is also a normal physiologic process, albeit less than ideal. It happens like this:

… [T]he natural water birth of her third child, a girl, at her home went horribly wrong in the early hours of March 27.

Ambulances were sent to the address following a triple-0 call made at 1.13am.

An ambulance service spokesman said paramedics were called to a Croydon Park address for a newborn baby who had suffered cardiac arrest and was not breathing.

Paramedics failed to revive the baby throughout the journey to the Royal Prince Alfred Hospital at Camperdown.

“They were basically working on the baby all the way to the hospital,” the spokesman said.

Looking at Fraser’s website and blog, I can find no mention of the dead baby. Indeed, I can find no evidence that Fraser has publicly mentioned the baby since her death. Not only was the baby’s life erased by her mother’s tragic self-absorption; the baby’s very existence has been blotted out to continue the illusion that unassisted childbirth is safe and “joyous.”

But a full term baby who dies in labor should not be forgotten so easily. Tell us, Ms. Fraser, how joyous is the birth if the baby is dead?

You may remember Gloria Lemay. She’s the Canadian lay midwife with no formal training who has learned nothing from presiding over a number of homebirth deaths. Now she has graced us with an obnoxious post entitled 7 Step Recipe for Creating an Autistic Child:

1.Allow ultrasound technicians to “date” your pregnancy, see if you have twins, check the growth of your baby. Even one ultrasound affects your baby’s brain. Multiple ultrasounds will move cells in the brain around and also affect future generations of your family.

2.Eat whatever you like in pregnancy. Don’t take the time and trouble to study the effects of over-processed, high fat diets. Don’t worry about buying organic produce and meat.

3.Let your physician induce you. Induction drugs over-ride Nature’s pace of the birth process. They cause prolonged periods of oxygen deprivation similar to holding a pillow over your child’s face. Any form of hurrying you into the birth process or, once into it, hurrying the process faster than it goes naturally will damage cells in the baby’s brain.

4.Take pain-killing drugs during your child’s birth. Every anesthetic goes immediately to the baby so choose whatever one you like. The longer the baby is medicated, the more brain damage is done.

5.Continue on with the interventions in birth by having a cesarean, forceps or vacuum pull out of your baby. None of these procedures are gentle. All involve incredible traction on the baby’s neck and head. Sometimes all three are used on the same baby. Risks of all 3 are increased when inductions and epidurals were brought into the birth.

6.Once your baby is born, feed him/her solutions made by pharma giants like Mead Johnson.

7.Be sure to inject your baby with every toxic pharmaceutical vaccine that your doctor recommends. Don’t do any research. 36 vaccines is the modern North American child’s recommended allotment of mercury preserved toxic waste.

How amazing. Scientists have been puzzling for years over the cause of autistic spectrum disorders and the latest evidence points to a genetic component, but Ms. Lemay, with NO RESEARCH of any kind, believes that she has solved the problem. And, coincidentally, it turns out that autism is caused by interventions in childbirth.

It’s all so simple. Autism is caused by ultrasound. Wait, no, it’s caused by eating the wrong food in pregnancy. Oops, I spoke too soon, it’s caused by pitocin. No, silly me, it’s caused by epidurals. Wrong again, it’s caused by C-section.

Hmmm, maybe it isn’t caused by interventions in childbirth after all. It’s caused by formula. Wait, no, it’s caused by mercury in vaccinations. Vaccines no longer have mercury in them? No problem, it must be caused by the vaccinations themselves.

Ms. Lemay is another winner of coveted “Skeptical OB Stupidity Trifecta award”. As an ignorant person with no formal training in science, statistics or medicine, she boldly goes were no stupid person has gone before. And, as a special bonus, she manages to be thoroughly offensive at the same time.

Here is a little background on Ms. Lemay. The following excerpt is taken from the judgment issued by the Supreme Court of Canada:

Sullivan and Lemay were hired by JV to provide private pre-natal classes and to act as midwives during a home birth. Although Sullivan and Lemay had some experience with home births and had done background reading, they had no formal medical qualifications.

After five hours of second stage labour, the child’s head emerged and no further contractions occurred. Sullivan and Lemay attempted to stimulate further contractions but were unsuccessful. Direct pressure was applied to the uterus, causing soreness to the mother’s stomach and back and some bruising. Approximately twenty minutes later, Emergency Services were called and the mother was transported to the hospital. Within two minutes of arrival, an intern delivered the baby using what the trial judge characterized as “a basic delivery technique”. The child showed no signs of life and resuscitation attempts were unsuccessful.

Sullivan and Lemay were jointly charged with one count of criminal negligence causing death to the child of JV contrary to s. 203 of the Criminal Code, and a second count of criminal negligence causing bodily harm to JV contrary to s. 204. They were tried in the County Court of Vancouver and were found guilty on the first charge and were acquitted on the second charge.

Lemay has also been convicted of criminal contempt of court for practicing midwifery without appropriate training and without a license. According to the College of Midwives of British Columbia:

On January 4, 2002, BC Supreme Court Justice Blair found Lemay guilty of criminal contempt of court for attending ten births over a five-month period in defiance or the court injunction. At sentencing, the judge rejected Lemay’s lawyer’s request to impose a conditional sentence. The judge said he was not satisfied a conditional sentence would protect the safety of the public. “This is not an isolated breach but a continued series of breaches,” the judge said in his oral reasons for judgement.

Late in January of 2002, just weeks after being found guilty, Lemay managed another labour planned to be a home birth, which was later investigated by the police after the parents filed a complaint. This non-progressive labour went on for more than two days. Lemay is alleged to have performed a number of restricted acts during that time, including artificially rupturing the membranes. When meconium was apparent, Lemay is said to have stayed at home with the labouring mother for many more hours.

During sentencing the judge made note of this incident, pointing out that when the fetus became compromised Lemay failed to accompany the mother to Burnaby Hospital and told the mother not to mention Lemay’s name to hospital staff. An emergency cesarean was required.

Justice Blair indicated that this incident exacerbated Lemay’s problem and was indicative of her character.

Justice Blair also noted Lemay was previously found in contempt of court for refusing to give testimony at an inquest probing the 1994 death of a newborn in her care. The inquest found that the baby died of cardiac arrest as a result of an infection acquired during this birth attended by Lemay.

Lemay, legally sanctioned for negligence in the death of two babies, and informally acknowledged to be present at other homebirth deaths is considered an “expert” in the homebirth community. Her inane pronouncements are what passes for “education” among homebirth advocates. The fact that she thinks she is in a position to offer “advice” to anyone is scandalous. The fact that anyone would take her “advice” is absurd.

Ms. Lemay is right about one thing, though. If you hire her as a midwife and your baby dies as a result of her idiocy, it will not develop autism. Somehow I doubt that is comforting to the parents of the many dead babies she has delivered.

It’s not often that you find scary stories in scientific journals, but a new paper in the journal Microbiology offers a scary story indeed. Effect of subinhibitory concentrations of chloride on the competitiveness of Pseudomonas aeruginosa grown in continuous culture does not sound particularly menacing, but this paper raises the spectre that the antibacterial cleansers used every day to clean our homes and ourselves may lead to bacteria that are resistant not only to the cleansers but to powerful antibiotics as well.

Americans have become obsessed with “germs.” While there are certainly harmful bacteria and viruses that we would do well to avoid, the environment is full of bacteria and viruses that are harmless to humans. Antibacterial cleansers target all bacteria, regardless of whether or not they are harmful. That might be appropriate in the setting of the operating room, but it is excessive in non-medical settings. Yet manufacturers of anti-bacterial cleansers suggest otherwise:

Some days it seems like the kitchen is more than the center of your house—it’s the entire house. It’s the room where you and your family gather and where your “stuff” tends to end up too. No matter how much it becomes the hub of your home, the kitchen is still where you prepare and eat your meals—and where you are probably most concerned about bacteria and other germs spreading from surface to surface. That’s why we’ve invented a simple solution that will help you easily keep your kitchen clean and disinfected.

Clorox® Disinfecting Kitchen Cleaner kills 99.9% of common household the bacteria and other germs that can make your family sick. Plus, its bleach-free formula also cleans countertops, tabletops, and tough surfaces like stainless steel to a streak-free shine. It’s an effective formula you can use on almost any surface.*

Well, maybe antibacterial cleansers aren’t really necessary in the home, but there’s no harm, right? Actually, it seems like the widespread use of these cleansers has the potential to cause serious harm.

The active ingredient in Chlorox Disinfecting Kitchen Cleaner, and many other antibacterial cleansers, is benzalkonium chloride. The authors of the new paper suspected that Pseudomonas aeruginosa bacteria can become resistant to benzalkonium chloride if they are exposed to low concentrations of the chemical. In addition, they postulated that if bacteria became resistant to benzalkomium chloride,they would also become resistant against antibiotics that kill bacteria in similar ways.

If Pseudomonas is exposed to high concentrations of benzalkonium chloride, all the bacteria will die. However, if the bacteria are exposed to lower concentrations of benzalkonium chloride, some bacteria will die, but others will become resistant to the antibacterial cleanser. That, in itself, is worrying. If we continually wipe down our kitchen counters with benzalkonium chloride, Pseudomonas will eventually become resistant, making the antibacterial cleanser useless.

Even more concerning is the fact that the bacteria that became resistant to benzalkonium chloride also became resistant to the antibiotic ciprofloxin, even though the bacteria had not been exposed to ciprofloxin. It seems that the adaptation that allowed the bacteria to resist the effects of benzalkonium chloride also allows the bacteria to resist the action of ciprofloxin.

In other words, the use of the antibacterial cleanser eventually rendered the cleanser ineffective. That’s disturbing, but not surprising. What is surprising is that the bacteria that were resistant to the cleanser could no longer be killed by the antibiotic ciprofloxin. In attempting to make our environment safer, we may actually be making it far more dangerous.

The problem of antibiotic resistance has been known for decades and we have learned that antibiotics should only be used when absolutely necessary in order to limit the possibility of bacteria becoming resistant. This paper suggests that the same warning should apply to antibacterial cleansers as well. They should only be used when absolutely necessary, and not used indiscriminately to “keep your kitchen clean and disinfected.” The use of antibacterial cleansers is not merely unnecessary; it has the potential to be very harmful.

Ricki Lake tweeted her followers this morning:

152 comments on our site
@mybestbirth.com taking on Dr.
Amy,AKA ‘The Skeptical OB’Check
out the amazing dialogue taking place. add your 2¢

Ms. Lake is referring to the post, Amy Tuteur, aka “The Skeptical OB,” Has a Blatant Issue With Home Birth, and the comment thread that extended for several weeks and 152 entries thusfar. I’m a bit surprised that Ms. Lake is proudly pointing to the discussion since I presented the scientific evidence on a number of aspects of homebirth and no one had an effective response. Here’s the latest comment I left on her site:

“I’m so glad that Ricki Lake tweeted her followers to check out this post. It gives me an opportunity to summarize what I have said and to point out the many inaccurate claims that Ms. Lake has made about homebirth.

I’d be happy to discuss with Ms. Lake any of the following facts that I presented (Ms. Epstein promptly disappeared from the comment thread when I offered to debate her):

1. Childbirth is INHERENTLY dangerous. It is and has always been one of the leading causes of death of both young women and babies.

2. The best study of American homebirth midwifery (Johnson and Daviss, BMJ 2005) actually shows that homebirth with a CPM has triple the neonatal death rate of hospital birth for comparable risk women. The authors hid this by failing to compare homebirth in 2000 with low risk hospital birth in 2000.

3. The CDC statistics for linked birth infant death show that homebirth with an American homebirth midwife is the MOST DANGEROUS form of planned birth in the US. Planned homebirth with a homebirth midwife has triple the neonatal death rate of low risk hospital birth.

4. The recent publication of the Dutch and Canadian studies is bad news for American homebirth. The studies shows that homebirth with an American direct entry midwife has more than triple the death rate of homebirth with a Canadian midwife or a Dutch midwife. The central lesson of both studies is that homebirth can only be safe when practiced by highly educated, highly trained midwives under rigorously controlled conditions, a position in direct opposition to the philosophy of American homebirth.

5. The Colorado Midwives Association reported its own mortality statistics. Colorado LICENSED midwives have an appalling rate of perinatal mortality of approximately 8/1000 (and rising), far exceeding the perinatal mortality rate for low risk births in Colorado.

6. Homebirth advocates like to quote US infant mortality statistics, but infant mortality is a measure of pediatric care. According to the World Health Organization, the correct measure of obstetric care is PERINATAL mortality and according to the World Health Organization, the US has one of the LOWEST perinatal mortality rates in the world, LOWER than Denmark, the UK and The Netherlands.

That’s just a few of the facts that I have presented. I would be happy to discuss them publicly with you any time Ms. Lake. A public discussion, in print or in person, would give all women the opportunity to evaluate your claims and my claims for themselves. If you are sure that you have made accurate claims you have nothing to fear.

I’d be happy to debate you in any neutral forum of your choice, Ms. Lake. How about it?”

Imagine an argument that goes like this.

Jane: Australians are thieves.
John: Can you prove that?
Jane: Are you saying that no Australians have ever stolen anything?

Jane has committed the fallacy of the lonely fact. Knowing that at least one Australian has stolen something, she has concluded that all Australians are thieves. The example of the Australians shows that it is an absurd “argument” but it is a favorite of “natural” childbirth advocates and lactivists.

For example:

NCB Advocate: Obstetrics is not evidence based.
Me: Can you prove that?
NCB Advocate: Are you saying that no principle of obstetrics has ever been proven wrong? Look at what happened with episiotomies.

Or:

NCB Advocate: C-sections are usually unnecessary.
Me: Can you prove that?
NCB Advocate: Are you saying all C-sections are necessary? I know for a fact that my cousin’s C-section was unnecessary.

Or a slightly different formulation:

Me: The benefits of breastfeeding have been overstated.
Lactivist: So you’re saying that breastfeeding is no better than bottle feeding?

In every case, the reasoning is based on the assumption that a specific example tells us something about the whole. The fact that episiotomies were used even though scientific evidence later showed them to have no benefit is used to justify the assumption that everything in obstetrics is used even though there is no scientific evidence to support it. A single (or a few) unnecessary C-sections are used to justify the assumption that all (or most) C-sections are unnecessary. In the third example, a single criticism of the benefits of breastfeeding is used to justify the assumption that I believe that breast feeding has no benefit at all.

The fallacy of the lonely fact is often used by “natural” childbirth advocates, lactivists, and many proponents of alternative health. It is meant to substitute for a lack of actual evidence. “Natural” childbirth advocates don’t know whether specific obstetric recommendations lack evidence, and they don’t want to bother finding out. They use one example and generalize to everything else. C-section activists don’t know what proportion of C-sections are unnecessary. The fact that some may be unnecessary is enough for them to assume that all (or most) are unnecessary. Lactivists routinely overstate the benefits of breastfeeding, and when question, don’t bother to find out the magnitude of the benefits. They prefer to claim that anyone who questions any benefits questions all benefits and therefore can be dismissed.

The fallacy of the lonely fact is a fallacy because it is based on the assumption that a specific example (episiotomies, for instance) can be generalized to the every possible example (all of obstetrics). Just as the fact that one or even more than one Australian stole something doesn’t make all Australians thieves, a single example can never be assumed to apply universally.

At first glance, the graph above appears to represent an indictment of contemporary obstetric practice. From 1970-1980, the C-section rate rose precipitously, and the neonatal mortality rate also dropped precipitously. Since then, the C-section rate has continued to rise ever faster, but neonatal mortality, although continuing, has declined at ever slower rates. Yet this is exactly what we would predict if the C-section rate were following the law of diminishing returns.

According to Wikipedia, the law of diminishing returns (also known as the law of marginal utility) means:

… in a production system with fixed and variable inputs (say factory size and labor), there will be a point beyond which each additional unit of the variable input (i.e., man-hours) yields smaller and smaller increases in outputs, also reducing each worker’s mean productivity. Conversely, producing one more unit of output will cost increasingly more (owing to the major amount of variable inputs being used, to little effect).

In the case of Cesarean sections, the law of diminishing returns would predict that there will be a point beyond which each addition increase in C-section rate yields smaller and smaller decreases in neonatal mortality rate.

Imagine a hypothetical first world country that has 1 million births per year. In this hypothetical country, we are able to analyze the number of lives saved by C-sections and we are able to analyze it in hindsight so that we know which C-sections were necessary. As the C-section rate rises, the numbers of lives saved drops off (diminishing returns). In our hypothetical country, we can chart how many lives are saved for each percentage point of the C-section rate. Each percentage point of the C-section rate represents 10,000 C-sections. Our chart might look something like this:

We can see the law of diminishing returns in action here. At a C-section rate from 0-5%, every C-section is necessary, and every C-section saves the life of both mother and baby. From 6-10% every C-section is necessary and saves the life of the baby. From 11-15% half the C-sections are necessary, resulting in a savings of 5000 lives. At rates higher than 15%, retrospective analysis reveals that far fewer C-sections are life saving. By the time a C-section rate of 35-40% is reached, only one additional baby will be saved every other year.

The results can be expressed another way. We can determine retrospectively how many C-sections were unnecessary. Here’s that chart:

So the law of diminishing returns tells us that, beyond a certain point, we will have to do more C-sections to save one neonatal life. In other words, beyond a certain point, we will have to do more unnecessary (in retrospect) C-sections for each life we save.

Of course, that tells us about C-sections in the aggregate, but the decision to perform a C-section is made on a case by case basis. Moreover, in court, the decision to find an obstetrician guilty of malpractice for not performing a C-section is also made on a case by case basis. The parents and the court really don’t care how many unnecessary C-sections you have to do to save one baby, if that baby is their baby.

Yet the C-section rate can be too high. When you get to the point that you are saving 1 baby every 10 years, the C-section rate is clearly too high. However, a tremendous premium is placed on the life of each and every baby. That societal value is reflected in the fact that our judicial system operates as if we believe that if a C-section had even a remote chance of preventing the death or disability, that C-section should have been done, and because it wasn’t done, the parents should be compensated.

The above graph represents what we appear to believe about the value of the life of each baby. Personally, I think the standard should be different. The number of unnecessary C-sections done to save one baby every decade should not be unlimited. The standard for determining fault in an obstetric malpractice case should not be to show that a C-section “might” have prevented a baby’s death or disability; the standard should be that the doctor could have reasonably foreseen (based on the evidence available) that a C-section was necessary to prevent the baby’s death or disability.

C-sections come with costs. We have not even talked about the financial costs, because, in my judgment, these are secondary. However, very large numbers of unnecessary C-sections will result in unnecessary complications and unnecessary deaths. If the C-section rate continues to rise, these unnecessary complications and unnecessary deaths will increase from relatively uncommon occurrences, to occurrences that far outweight the number of babies’ lives saved.

We, as a society, need to think about where we draw the line, because we, as a society, through our punishments and incentives, determine how high the C-section rate should be. The graph above is not an indictment of obstetrics. It is a warning to us to consider what we truly value. Do we really believe that it is worth any number of C-sections to save one baby’s life? We certainly act as though we do.

On its website, Midwifery Today features a timeline entitle The History of Midwifery and Childbirth In America. The timeline extends from 1660 to the late 1990’s. It contains interesting tidbits of information about childbirth practices, interspersed with general historical events. It seems quite comprehensive with the exception of one curious omission. It barely mentions mortality statistcs.

To my mind, the history of childbirth is a continuing effort to master its inherent dangers. Childbirth is and has always been, in every time, place and culture, one of the leading causes of death of young women and the leading cause of death of newborns. Indeed, the primary purpose of a childbirth attendant is to increase the chance that the mother will live, at least, and hopefully the baby will live too.

The secondary purpose of a childbirth attendant is to comfort the mother as she endures the excruciating pain of labor. The history of childbirth has also been a continuing effort to master the pain of childbirth. That’s another curious omission from the Midwifery Timeline. It makes no mention of chloroform, general anesthesia or epidurals, arguably among the most important advances in the history of childbirth.

I suspect that the reason for these glaring omissions reflects the direct entry midwifery obsession with process. The outcome, whether or not the mother or baby lived, is virtually irrelevant.

Perhaps another reason why the timeline is silent on the issue of mortality statistics is that they illustrate the spectacular success of modern American obstetrics. For hundreds of years midwives presided over childbirth and had almost no impact on the appalling rates of maternal and neonatal mortality. It was only with the advent of modern obstetrics that the mortality rates began to fall.

I thought it might be interesting to look at the statistics that the Midwifery Today timeline left out. I took as the starting point the timeline itself. It faithfully chronicles the movement of birth from the home to the hospital starting in 1900. In every decade, it reports the ever increasing percentage of hospital births. Yet it is silent on massive declines in maternal and infant mortality that occurred simultaneously. For each point in the timeline where the percentage of hospital deliveries is mentioned, I looked up the corresponding maternal and neonatal mortality rates. The above graph is the result.

As the percentage of births in the hospital rose, the maternal and neonatal mortality plunged. The graph is a powerful way of demonstrating that the association is dramatic. During the 1900’s, for the first time in history, using the tools of modern obstetrics, the terrible inherent dangers of childbirth were mastered. Could we do even better? No doubt, and the search continues to make birth even safer than it is today. As Dr. Atul Gawande wrote in his New Yorker article (The Score, How childbirth went industrial), “Nothing else in medicine has saved lives on the scale that obstetrics has.” The graph makes that very clear indeed.

Infant and maternal mortality rates abstracted from CDC on Infant and Maternal Mortality in the United States: 1900-1999. Although neonatal mortality is a much better measure of obstetric practice, neonatal mortality figures were not collected in the earlier part of the century. Therefore, infant mortality statistics are used as a proxy, albeit imperfect.