When I announced my fourth pregnancy to my boss, I was startled by her response.

“What’s the matter with you? You’re a gynecologist; if anyone should know about birth control, it’s you.”

“It wasn’t an accident,” I replied. “We want a fourth child.”

I have never forgotten her look of disbelief.

She was not the only one who was amazed. For every person who congratulated us on the news, there was another who offered “condolences.” For them, the decision to have another child was bewildering. Why would anyone make that kind of commitment?

It is this amazement that is at the heart of America’s current fascination with big families. TLC (The Learning Channel) has led the way in catering to that fascination. From Jon and Kate Plus Eight, to Table for 12, through The Duggars: Eighteen and Counting, we can’t seem to get enough.

Why are we fascinated? It’s not about the cute children, since the newer shows have teenagers and young adults, as well as a severely handicapped child. I suspect we are fascinated because we stand in awe of the commitment required to deliberately choose a large family: the commitment to parenting as a lifestyle choice and the commitment to marriage that lies at the core of the decision to have many, many children.

In contemporary America, such a commitment is not only unfashionable; it is unfathomable.

If contemporary America could be distilled to one imperative, it would be this: The highest calling is self-actualization. Or, more colloquially, “it’s all about me.” In other words, being happy (and being happy is considered the highest state of being) requires doing what you want, when you want to, unfettered by obligations and commitments. Children are an obligation, a temporary detour on the road to a life devoted to self.

The Pill has been cited as the central reason for the shrinking of American family size, and that’s true as far as it goes. The Pill has allowed American parents to choose the size of their families, instead of making do with unintended results of sexual activity. Yet the Pill is not responsible for the belief that a smaller family is better. That is a product of our philosophy.

When the highest calling is following every personal wish and whim, commitment to someone else can seem exotic indeed. Half of married couples can’t manage to maintain a commitment to the person they promised to love, honor and cherish forever. Last year almost 40% of women giving birth couldn’t manage to meet the most minimal commitment to their newborn, that of providing a father to support and nurture that child.

Even within a secure marriage, most couples cannot fathom willingly undertaking the sacrifices necessary to support and nurture more than two children. Children are important accessories to a “good life” but very few Americans seem to believe that children represent a “good life” in and of themselves. Having more than two children makes about as much sense to them as wearing more than two socks at a time. Why would anyone bother?

To watch the day to day life of parents who have committed to large families is like watching an exotic animal in its native habitat. Look, they put children’s needs ahead of their own, and they enjoy doing it. Wow, they’re not obsessed with following their own desires and whims. Amazing, the parents are not obsessed with having as much discretionary income as possible.

What feeds our obsession with super size families is not the logistics of caring for so many children. It is the commitment, to spouse, to children, to the family itself that undergirds the decision to have a large family. Octomom Nadya Suleman misunderstood that crucial point. She thought that by having a mega family she would be guaranteed a TV show and lots of merchandising opportunities. She didn’t understand that no one wants to watch a selfish, mentally disturbed woman who collects children as if they were trinkets. They want to see adults who value and live commitment to others.

That’s also why we’re obsessed with the state of Jon and Kate’s marriage. Husbands cheat on wives every day of the week, but this is a special case. We thought Jon and Kate were more committed to their family than to themselves as individuals. We’re disappointed in Jon because he turns out to be just like everyone else.

The current popularity of TV shows following large families is not about the children; it’s about the parents. In a world that values self actualization as the highest human aspiration, adults who put others before self, who believe that marriage is forever and children are not “accessories” to life but are life, inspire curiosity, admiration and fascination.

It’s been many years since the magazine Cosmo has spoken to me. Cosmopolitan Magazine, the ultimate achievement of editor and writer Helen Gurley Brown (Sex and the Single Girl) is aimed at women 18-30 and concentrates on the old fashioned pre-occupation of landing a man. Of course landing a man used to mean getting him to marry you; Brown’s great innovation was to insist that “landing” him simply meant getting him into bed. Setting the bar a lot lower made the chances of success a lot higher.

Fortunately, Gurley-Brown has not forgotten older women like me. Her books offer advice for how to keep a man, once you have landed him. The principle is the same; only the specific tactics need to be modified.

What is the principle? Simply put, sex is all about him. Women exist primarily for the sexual satisfaction of men. Not coincidentally, that is the central premise of pornography. As if the objectification of women in men’s magazines were not bad enough, women’s magazines like Cosmo emphasize the point: Your sexual needs and desires are irrelevant, ladies. What matters about your sexual needs is not their fulfillment, just the effect that your fulfillment has on men’s enjoyment.

Case in point, a typical Cosmo cover featured Total Body Sex, the Naked Quiz, The Trick that Attracts Hot Guys Like Crazy, and, my personal favorite, Your Orgasm Face; What He’s Thinking When He Sees It. Not only are women being judged for sexual attractiveness (evidently the only characteristic of concern), they are being judged on how they look during sex. You might be pretty, you might be thin, you might be well endowed, and that will convince him to take you to bed, but he’s still entitled to judge your performance during sex and finding you lacking. Because, repeat after me, ladies: Sex is all about him.

Gurley-Brown thinks it is important for “older” women to understand that while the principle is the same, the tactics must be modified. In the section Lovemaking for Grown-up Girls (from her book I’m Wild Again), she explains:

When a woman is, say, up to thirty, all she has to do is show up for the lovemaking, cooperate and be adored… When she is fifty, sixty, maybe only forty, the most successful lovemaking is her doing things to him…

At that advanced age, sex is all about his penis:

…the stroking, loving, sucking, handling and, most of all, the admiring thereof… [He might] prefer a younger, less puckered up body but hands belonging to that body wouldn’t do the things we can and will do so adroitly…

Thank goodness that women in an advanced state of decrepitude (over 40) have at least one advantage over the younger and less puckered.

Gurley-Brown claims to be a feminist, and perhaps when Sex and the Single Girl was written in 1962, sexual openness passed for feminism. However, it seems to me that Gurley-Brown has confused explicitness with empowerment. She may be willing to discuss sex openly and explicitly, but sex in her mind is still all about men and what she presumes to be their needs.

In the supposedly repressed 1940’s and 1950’s, sex was a wife’s “duty” to her husband in exchange for marriage and economic support. In the early 2000’s sex is still a woman’s duty, though it is no longer rewarded with marriage and economic security, merely the presence of a warm body in bed. That doesn’t sound like progress or feminism to me.

It’s not easy to gross out a gynecologist. The job involves constant exposure to bodily fluids of all types, especially blood. And delivering a baby is in a class by itself. Even a normal birth ends up looking like Texas chain saw massacre, plus excreta of various kinds.

So when my office assistant came to warn me that the next patient had a disgusting problem, I raised by eyebrows in surprise. What problem could be so bad that it would gross out a gynecologist?

The assistant didn’t know what the problem was, but it had required unusual measures. The odor emanating from the young woman was so offensive that she could not be allowed to sit in the waiting room. The assistant had escorted her to a private exam room the moment that she presented at the front desk.

My assistant was not exaggerating. When I opened the door to the exam room and stepped in to introduce myself, I was assailed by a truly repulsive odor. I struggled to maintain a welcoming look and avoid any sign of disgust. Patients may have birth defects or injuries that frighten others, but they should never feel that a doctor is shocked.

The patient was weeping.

“I don’t know what is wrong and I can’t get rid of this odor. It’s been getting worse for the last week and in the past few days I haven’t even been able to leave my house. Each day I have even more of this awful smelling vaginal discharge and no matter what how many times I wash I can’t make it go away.”

Typically I start by taking an extensive history, but I was not sure I could stay in the room for very long.

“Let’s start with the pelvic exam,” I suggested, “since the most important thing is to find out where the discharge is coming from.”

The patient positioned herself on the exam table, weeping quietly all the while. I prepared myself to find a decomposing tumor or a strange infection. I inserted the speculum and tried not to retch.

I saw it right away. It was an old tampon.

“When was your last period?” I managed to choke out.

“It ended about a week and a half ago. Why?” the patient replied.

“You forgot to take out your last tampon. It’s been in there for more than a week. That’s the source of the odor.”

The young woman was both relieved and embarrassed.

“You mean there’s nothing wrong with me? This will go away?”

“Absolutely!”

I carefully extracted the tampon and placed in a biohazard receptacle. I called for my assistant to remove the biohazard container and take it to waste disposal. Immediately the air in the room became easier to breathe. I cleaned out the vagina with water and was amazed to see that there had been no damage to the sensitive tissues in the surrounding area.

I waited while the patient got dressed behind a curtain. We discussed that it might take a day or more for the odor to dissipate entirely, but since there was no permanent damage, I was sure that it would be gone soon.

The patient embraced me.

“Thank you so much. I’m so relieved.”

I returned her embrace and led her to the door, carefully closing it behind her. Then I turned and vomited into the exam room sink.

My sister-in-law Sarah* passed away in February of last year after a brutal 6 year battle with ovarian cancer. She was only 49 years old and left a 9 year old daughter and husband. Her sojourn through the healthcare system illuminated both the incredible triumphs and the glaring defects in American medicine.

Ovarian cancer is a very bad disease. Because the ovaries are located deep within the body, ovarian cancer usually produces no symptoms until it has advanced to stage III of four possible stages. At that point, the 5 year survival rate has dropped dramatically, from 85-90% at stage I to 40% or less. Survival depends on aggressive treatment with surgery and chemotherapy.

The fact that Sarah survived for 6 years is a testament to the determination and ingenuity of her oncologist. Every time Sarah failed a regimen, and she failed many, the oncologist had a new regimen in reserve.

That treatment is physically grueling, but the encounters with the healthcare system that are necessary to access the treatment represent additional hurdles. Anyone who has read my previous posts knows that I am very cynical about the system, but I even I was repeatedly startled by the callousness and insensitivity of some of the incidents. I would not believe some of them had I not actually been there to witness them. One of those incidents was the meeting in which the doctor revealed to my sister-in-law that her disease had returned, was incurable and was facing certain death.

All along I was very involved in her care. I had arranged her original surgery and carefully followed her initial treatment with powerful chemotherapy. As a general matter, though, I did not accompany her to doctor’s appointments, preferring to clarify the few instances of concern by phone conversations. Approximately a year after the diagnosis, Sarah and her husband were scheduled to meet with her oncologist to discuss test results from new biopsies; she was afraid of bad news. I expected that she was going to get bad news because her new symptoms and her recent PET scan results were very ominous. I didn’t want to be there, and tried to beg off.

Sarah begged me to come. “I need you there because I don’’t understand the doctor.”

Sarah’s first language was not English, but her English was excellent and I was surprised that she thought she would have difficulty understanding.

She saw my confusion. “No, it’s not the language,” she said. “The doctor speaks too fast.”

I didn’t really understand the problem, but Sarah was so distraught, that I agreed to be there. I knew she was going to get bad news, so she deserved to have help handling it, if that is what she wanted.

Sarah was getting her care at one of the world’s greatest cancer centers. We met at the doctor’s office and waited more than an hour and a half before she appeared. The oncologist swept into the room, and with very little preamble began delivering the bad news at a rapid fire pace. I could see Sarah was confused.

“Wait a minute, wait a minute,” I said to the doctor. “I know what you are going to say, and I can’t understand you. Please slow down so Sarah can follow along.”

The doctor shot me a look of annoyance, but complied. She proceeded to tersely but slowly deliver the bad news. The biopsies showed that the ovarian cancer had returned less than 6 months after Sarah had finished rigorous chemotherapy. This was the worst possible sign. The fact that the cancer had returned so soon meant that she had failed the most aggressive chemotherapy in the arsenal. There was now no real chance to cure the disease; only a variety of treatments that might hold the cancer at bay for a few months or a few years.

The extent of the cancer’s return had not yet been established and that would help determine the amount of time she had left. An additional test was needed, and until those results were in, the doctor could not be more specific.

Sarah, already distraught, reported that she had been trying to get the doctor’s secretary to book to the test for weeks, and the secretary had not complied. Sarah did not know what to do next.

The doctor replied. “You’ve got to understand that we are very busy here. You’ll just have to wait until she gets around to it.”

“But I have cancer,” Sarah implored.

I would not have believed what happened next if I had not been there myself to witness it.

“Well, Sarah, everybody here has cancer, so you’ll just have to wait.”

Sarah burst into tears. The appointment was clearly over and the doctor moved to leave the room.

“I need to speak to you privately,” I called, as I got up to follow her out. I looked at Sarah. “With your permission, of course.” She nodded.

The doctor and I went out into the hall.

“Look,” I said, “I’m not going to ask you to cure Sarah. I know that’s impossible now.” I continued, “I don’t know how much time she has left, but for the remainder of that time could you please treat her with decency? She’s 44 years old, she has a 4 year old child, and she’s dying. Could you at least be nice?”

The doctor looked abashed. “Yes,” she said simply.

By and large, the doctor kept her word. We had a few minor incidents and only one major incident over the ensuing years. While the quality of the oncologist’s actions occasionally left much to be desired, the quality of her medical care was outstanding. She was clearly deeply invested in helping Sarah gain every additional day she could to raise her daughter. She never gave up, she never got discouraged, and she never ran out of treatment ideas, many of them cutting edge.

I have no doubt that she is a brilliant oncologist and her knowledge and commitment allowed Sarah to survive far longer than anyone’s most optimistic assessment. It’s difficult to reconcile that knowledge and commitment with the rudeness and disrespect of some of the encounters that happened along the way. In one way, though, it is not surprising. It is typical of the American healthcare system, combining brilliance, ingenuity and commitment with callousness and insensitivity.

* Not her real name

One of the most attractive aspects of vaccine rejectionism, indeed of all “alternative” health, is that no particular knowledge is necessary to declare yourself an expert. It doesn’t matter that you don’t have even the most basic knowledge of science and statistics. It doesn’t matter that you don’t have any understanding at all of the complex fields of immunology or virology. Your personal experience qualifies you as an expert. Hence Jenny McCarthy and Jim Carrey, two actors with no training of any kind in science, are touted by themselves and other as “experts” on vaccination.

As the paper The Persuasive Appeal of Alternative Medicine explains:

The person-centered experience is the ultimate verification and reigns supreme in alternative science… Alternative medicine makes no rigid separation between objective phenomena and subjective experience. Truth is experiential and is ultimately accessible to human perceptions… [O]bjective diagnostic or laboratory tests that discern what cannot be felt never replace human awareness… [A]lternative medicine, unlike the science component of biomedicine, does not marginalize or deny human experience; rather, it affirms patients’ real-life worlds. When illness (and, sometimes, biomedicine) threatens a patient’s capacity for self-knowledge and interpretation, alternative medicine reaffirms the reliability of his or her experience.

On its face, such an appeal seems ludicrous, but it provides powerful validation for people who are frightened and confused:

You don’t have to listen to experts; you are an expert.
It doesn’t matter what studies show about whether vaccines cause autism; it only matters that it seems to you that vaccines cause autism.
Your personal experience isn’t irrelevant to determining whether vaccines cause autism; it is the central, perhaps the only, thing you need to know to make a determination.

Vaccine rejectionism implicitly reflects the conviction that no particular knowledge is necessary. Both immunology and virology, the foundations of vaccine science, are extremely complex. They are not as arcane as, say, the Einstein’s Theory of Relativity, but they require years of study and a fund of specialized, technical knowledge.

Vaccine rejectionists simply ignore this point. It’s not that they claim to have any knowledge of immunology or virology. They simply behave as if such knowledge is unnecessary. Merely having a child who is autistic and has been vaccinated (against anything, at any time) automatically qualifies them to pontificate on the claim that vaccination “causes” autism. They believe that their “personal experience” of vaccination makes them as experts on vaccination, which is the equivalent of claiming that their “personal experience” of gravity qualifies them as experts on Einstein’s theory.

Vaccine rejectionists attempt to justify the lack of understanding of science and statistics, let alone immunology and virology, by making disparaging claims about the value of science itself . These are claims make by people who clearly feel threatened by knowledge. It is not coincidence that these claims have been invoked by flat-earth theorists, and creationists as well as by purveyors and supporters of vaccine rejectionism. Such claims include:

There are areas of knowledge that are not accessible to science.
Statistics cannot tell us everything about what happens.
Science tells us something different than experience tells us.
Science does not tell us the truth because it is manipulated by scientists for their own ends.
Science does not tell us the truth because it is manipulated by business people for their own ends.
There is no such thing as scientific truth.

These claims are not merely a justification of lack of knowledge; they are an affirmative celebration of ignorance. Vaccine rejectionism is not simply based on factual errors and a pervasive failure to understand basic science and statistics, as well as immunology and virology. It is also based on a denial of the need for specific knowledge and a disparagement of such knowledge. By elevating “personal experience” to the same or even higher level than actual knowledge of the relevant subject matter, vaccine rejectionism makes everyone an “expert.” Instead of imparting new knowledge, instead of protecting children, however, it merely flatters the ignorant.

People who live in glass houses shouldn’t throw stones.

Conservatives, who bemoan same-sex marriage as a potential cause of family breakdown, are hardly in position to point fingers. The sad state of opposite-sex marriage, particularly among conservatives themselves has caused and continues to cause family breakdown, and, indeed, societal breakdown. If conservatives spent more time tending to their own marriages, and less worrying about other people’s marriages, children, families and society would be better off.

To listen to conservatives, religious and political, you’d think that same-sex marriage represents a significant threat to health, wealth and morals. To my knowledge approximately zero people have been harmed by same-sex marriage. I guess it’s easier to pontificate about a non-threat rather than to face the real threat, the breakdown of opposite-sex marriage. Illegitimacy, divorce and child abandonment harm hundreds of thousands of children, and many adults each and every year. That represents a major threat to health, wealth and morals.

The statistics on the breakdown of opposite-sex marriage are incontrovertible; divorce breaks up a large proportion of families, illegitimacy (failure to marry) is a major risk factor for child poverty, poor health, and criminal activity. Child abandonment (usually by the father) leaves many children, betrayed, bereft and poverty stricken.

Why do conservatives, religious and political, waste their time trying to destroy or prevent same-sex marriages when opposite-sex marriages are clearly a source of so much pain and suffering? Perhaps it’s because those very same conservatives are responsible for so much of the devastation.

Which states have the highest rates of divorce? Conservative states. Which states have the highest rates of illegitimacy? Conservative states. It’s not a coincidence that the first divorced president (Ronald Reagan) was a conservative or that the first presidential candidate to parade an unwed pregnant teen child on national television was also a staunch conservative (Sarah Palin).

When it comes to health, wealth and morals, the issues that conservatives claim undergird their opposition to same sex marriage, conservative states lead the way … to the bottom. Health: States with the highest rate of infant mortality? Conservative states. Wealth: States with the highest rate of child poverty? Most are conservative states. Morals: Many of the states with the highest rate of teen drug abuse are conservative states. An unbiased observer might be forced to conclude that it is the breakdown of opposite-sex marriage that threatens the well being of Americans, particularly American children.

It is a curious fact about American conservatives, political and religious, that they fail to recognize that they are the problem, not the solution. The values that they claim drive them to oppose same-marriage are being undermined by their behavior, not the behavior of others. Their party stalwarts are drug addicts (Rush Limbaugh), philanderers (Newt Gingrich), and people who found divorce both personally and financially convenient (Ronald Reagan, John McCain).

It is not a stretch to argue that the people who really support family values are the people who are trying to form families, same-sex couples, not the people who loudly and stridently promote “family values” while conspicuously failing to practice them.

That’s not the official plan, of course. Bristol Palin has been hired by a national foundation ostensibly to “raise awareness” for teen pregnancy prevention. It seems a decidedly poor choice since Bristol Palin has done more to glamorize teen pregnancy than any other individual.

Palin’s story is hardly a cautionary tale. The typical teen pregnancy is shadowed by shame, fear and the specter of poverty. Bristol’s teen pregnancy differed not simply because her avowedly Fundamentalist mother, the governor of Alaska, has publicly supported her, both emotionally and financially. The principle difference is that Bristol’s unwed teen pregnancy catapulted her to a life of national celebrity.

Rather than being viewed as a source of shame to be hidden away, Bristol Palin and her boyfriend were proudly displayed at the Republican Party Convention. John McCain, attempting to bask in the light of her celebrity, actually went to the airport to greet her and the baby’s father when they arrived in Minnesota. She made multiple appearances on national TV and her story was breathlessly covered by celebrity publications like People Magazine. Bristol Palin has continued to bask in her new-found celebrity since the baby’s birth. In a February interview by Fox News, she declared that teen sexual abstinence is “not realistic at all.”

Prior to Bristol Palin’s appearance on the national stage, I had thought we reached a new low on the teen pregnancy front when Jamie Lynn Spears announced the impending birth of her baby and I had to explain it to my tween daughter. I wasn’t getting much support for my views and values when Spears was glamorized by being featured prominently on national magazine covers, complete with stories of her dreamy musings on how she was “ready” to become a mother.

As a gynecologist and a mother, I have spent decades counseling young girls to avoid teenage pregnancy. My recommendations always include delaying sexual activity, using contraception, and considering future goals and the way that teen pregnancy tends to make them unachievable. I didn’t expect any help from the entertainment press, but I was surprised nonetheless by how easily Spears’ pregnancy was accepted, how her pre-baby planning and purchases were portrayed as normal events for a 16 year old, and how she and her baby appeared on national magazine covers. Despite that, I was blindsided by the willingness, even eagerness, of the Republican Party and the national press to glamorize Bristol Palin.

No family is perfect, poor decisions are made, and children should be loved and supported in their aftermath. Nonetheless, call me old fashioned, but I don’t think that being supportive of your child’s poor decisions means proudly parading her on a national stage. I certainly don’t think that being supportive means flying in her teenage boyfriend so he can appear with her in the national limelight. If that isn’t glamorizing teen pregnancy, I don’t know what is.

Bristol Palin hired to promote awareness of teen pregnancy? Does her story — get pregnant, have your pregnancy supported by your famous mother, have your boyfriend invited to join you on national television, be personally greeted at the airport by the Republican presidential candidate, give interviews to celebrity magazine — discourage teen pregnancy or promote it?

Pick up any newspaper or magazine and you can read about the latest scientific breakthroughs in cancer, Alzheimer’s or heart disease. Just keep in mind that what you are reading is probably not true.

The research was done just as reported. The results were written up just as the newspaper article states, and the quotes from the scientific researchers are accurate. Unfortunately, the odds are high that the research does not mean what the authors would like you to think it means, and the reason points to a fundamental failing of medical journalism.

Medical journalists are supposed to interpret the findings of recent medical publications and present them to the general public in ways that they can understand. They are supposed to provide context for the discovery, explaining what it might mean for disease treatment or cure. Yet, they rarely do. Instead, they simply copy the press release.

Most people are unaware that scientists issue press releases about their work and they are certainly unaware that medical journalists often copy them word for word. Instead of presenting an accurate representation of medical research, medical journalists have become complicit in transmitting inaccurate or deceptive “puff pieces” designed to hype the supposed discovery and hide any deficiencies in the research.

Imagine if a journalist reviewing the newest Ford cross-over vehicle didn’t bother to drive the car, but simply copied the Ford brochure word for word. Could you rely on the journalist’s evaluation? Of course not. Yet that is precisely what medical journalists are doing each and every day.

A paper in a recent issue of Annals of Internal Medicine confirms this disturbing trend. The paper, Press Releases by Academic Medical Centers: Not So Academic?, by Woloshin, and colleagues finds:

Of all 113 releases about human studies … [f]orty percent reported on inherently limited studies (for example, sample size <30, uncontrolled interventions, … or unpublished meeting reports). Fewer than half (42%) provided any relevant caveats… Among the 87 releases about animal or laboratory studies, most (64 of 87) explicitly claimed relevance to human health, yet 90% lacked caveats about extrapolating results to people… Twenty-nine percent of releases (58 of 200) were rated as exaggerating the finding’s importance… Almost all releases (195 of 200) included investigator quotes, 26% of which were judged to overstate research importance… Although 24% (47 of 200) of releases used the word “significant,” only 1 clearly distinguished statistical from clinical significance. All other cases were ambiguous …

Why is this a problem? The harm extends beyond the obvious point that it is deceptive, and a failure of medical journalists to do their job, which is to interpret the accuracy and relevance of scientific publications when writing about them. Because medical journalists credulously publish press release as if they were true, they are constantly publishing conflicting reports, contributing to the public’s distrust of medical research. Each day seems to bring a new report of a food, or a drug that will prevent or cure cancer. Within a week or a month or a year, the journalists are reporting that that food or drug does not prevent or cure cancer.

To the public, it looks like medical researchers are constantly making mistakes. Today they claim that a food will prevent cancer. Next month, the same food will be found to cause cancer. In reality, medical research never demonstrated either claim, but medical journalists reported preliminary findings or flawed research as if they were definitive even though that was untrue.

The Annals of Internal Medicine has done an important service in bringing this disturbing practice to light. You can’t believe what you read about medical research in newspapers and magazines because medical journalists are simply copying press releases, not analyzing the research for accuracy or relevance. Therefore, in the interest of accuracy and relevance, I must disclose an important caveat to this important scientific paper. In what surely is an unintentional irony, The Annals of Internal Medicine publicly unveiled the paper and its findings by issuing a press release.

My most difficult obstetric case was not a diagnostic dilemma, but rather an ethical one. Everyone involved agreed on the diagnosis, but the experts split neatly down the middle, each group offering a treatment plan diametrically opposed to the other. We had no difficulty agreeing on the nature and severity of the problem. We just couldn’t figure out what to do about it.

The patient was sent to me, the on call doctor, directly from the office where she had just had an ultrasound exam. The radiologist, an exceptionally skilled clinician, called me to tell me that this was an emergency that required immediate action. She insisted that without a C-section, the patient’s twins would both be dead in a matter of hours. These babies were exceptionally small because their placenta was failing. Oh, and there was an additional complicating factor. They were also very premature, only 27 weeks (more than 3 months early) by best estimate, so prematurely delivering them now would probably kill them.

The mother was a 24 year old woman with a history of 2 normal deliveries. She had shown up for her first prenatal appointment only 8 weeks before, knowing she was pregnant, but unsure when she conceived. The first ultrasound showed a twin pregnancy at approximately 19 weeks. The problems were apparent even then. Both babies were exceptionally small, less than half the expected weight for that point in pregnancy, and an abnormal placenta with sluggish blood flow was clearly the cause. She was counseled that the babies would probably die before they were old enough to survive outside the womb.

A repeat ultrasound at 23 weeks showed that the babies, both boys, were still alive, but had not grown much. Now an ultrasound at 27 weeks had demonstrated that each weighed less than a pound (as compared to an expected weight of two pounds) and both were near death. At 27 weeks of pregnancy, there was a theoretical possibility that they could survive if delivered now.

We called a perinatologist, an expert in pregnancy complications, to consult on the case. She confirmed the findings of the radiologist, and told the patient in no uncertain terms that she expected that the babies would die if not delivered soon. Then we called a neonatologist, a specialist in the care of newborn infants, and he was equally adamant that the babies should not be delivered.

The neonatologist described to the mother the daunting odds that her sons would face, the myriad of possible complications, and the lifetime handicaps that would be expected if they lived. He warned ominously that the NICU (neonatal intensive care unit) of this hospital, one of the finest in the world, have never had a baby that small survive. The neonatologist counseled her that these babies should not be delivered for several more weeks. Delivering them now, he claimed, was the equivalent of a death sentence.

The mother could not decide what to do. Her husband and family arrived, followed shortly by her minister. She asked me what I recommended and I hesitated. I believe that it is the job of a doctor to make a recommendation, even though the decision is up to the patient. She had heard a lot of highly technical and conflicting medical advice and needed help in sorting it out, but I wasn’t sure what to do, either. It seemed like any decision would be the wrong decision.

Ultimately I told the mother that I felt that her sons were going to die no matter what she chose. In the future, though, she would probably look back on this tragedy and wonder if she had done everything she could. So the best way to make the decision would be to imagine what would give her the most comfort during the rest of her life. Would she feel that she had done the most for her babies by keeping them inside and hoping they would survive long enough to have a better chance at life? Or would she feel that she had done the most for them if she had surgery today and consented to very aggressive and probably futile attempt to save them that way? The mother requested more time to pray on her decision.

When I returned, she had decided. She understood, she said, that it was likely her sons would not survive. Nonetheless, she would never forgive herself unless she did everything she possibly could for them. To her, doing everything meant submitting herself to a C-section and consenting to maximally aggressive treatment of the babies.

We assembled a surgical team and two separate neonatology teams, one for each baby. We headed to the operating room for the birth and death of her sons.

The surgery itself was uneventful. The first baby was pulled from the uterus and handed off to the neonatologist. He had only a heartbeat and no other signs of life. He weighed a mere 16 oz. The neonatologist promptly intubated him and began aggressive treatment measures. The baby never responded and died in the operating room.

The second baby was born. He squeaked as he was given to the neonatologist. This boy was even smaller than his brother, weighing in at only 15 oz. He too was promptly intubated, but needed surprisingly little assistance to stabilize despite his dire condition.

This tiny boy had a precarious existence in the NICU, but day by day continued to defy the odds. Ultimately, despite multiple complications and three months in intensive care, the baby became the smallest survivor to every leave our nursery. He went home with some visual impairment due to prematurity and some lung damage due to the long course on the respirator. The last time I saw him was shortly after his fifth birthday. He was small and he needed glasses, but in every other way he was a normal little boy.

What did we learn from this case? To this day, I don’t really know. Never before and never since have I been in a situation with such stark choices and so little hope. The mother made the choice that she thought would give her the most comfort and to our amazement, and hers, a tiny boy survived seemingly insurmountable odds as a result, in the process making history at our hospital.

Following up on her film “The Business of Being Born.” self proclaimed childbirth expert, actress Ricki Lake has published a new book. Hopefully, it is more accurate than her movie, but I have my doubts, given her deceptions and misrepresentations about homebirth.

Childbirth is and has always been one of the leading causes of death of young women and babies in every time, place and culture. Finally, for the first time in human history, that has changed if you happen to be living in the right place. American obstetrics has been spectacularly successful in lowering the neonatal mortality rate 90% and the maternal mortality rate 99% in the past 100 years. In response, homebirth advocates like Ricki Lake have suddenly discovered the joys of giving birth at home.

Homebirth advocacy is supposed to be about “empowering” women to make “informed” health care decisions. How that could happen when homebirth advocacy is based almost entirely on mistruths, half truths and outright lies? Ricki Lake is out front in spreading these deceptions and she ought to stop. In a recent piece on the Huffington Post (Docs: Pay No Attention to Ricki Lake’s Homebirth), Lake claimed:

“In fact, the largest and most rigorous study of home birth internationally to date found that among 5,000 healthy, ‘low-risk’ women, babies were born just as safely at home under a midwife’s care as in the hospital.”

That’s flat out false. All the existing scientific evidence shows that homebirth increases the risk of neonatal death. Sure, there are papers that claim that homebirth is a safe as hospital birth, but they do so by comparing homebirth to high risk hospital birth (instead of low risk hospital birth) or by comparing homebirth in one year to hospital birth decades before (as in the Johnson and Daviss BMJ 2005 study that Lake mentions).

Johnson and Daviss claimed to show that homebirth with a CPM in 2000 was as safe as hospital birth, but they compared it to hospital birth in a bunch of out of date studies extending back to 1969. Johnson and Daviss simply left out the fact that homebirth in 2000 had almost triple the neonatal mortality as moderate risk hospital birth in 2000.

In an interview on the Today Show, Lake declared:

“The fact that we have the second-worst infant mortality rate in the developed world is a statistic that I think people need to know about”

However, infant mortality is not the correct statistic to evaluate obstetric care since it includes deaths up to one year. According to the World Health Organization, the correct statistic to evaluate obstetric care is perinatal mortality, death from 28 weeks of pregnancy to 28 days of life. The World Health Organization 2006 report on perinatal mortality shows that the US has one of the lowest rates in the world, lower than Denmark, the UK and the Netherlands.

Lake continued:

“Home births and midwives are more common in Japan and Europe than in the United States …”

What Lake neglects to mention is that American homebirth midwives belong to a second, inferior class of midwives with less education and training than ANY midwives in the industrialized world. American CNMs and European midwives deservedly have excellent reputations. They have rigorous educational requirements and extensive hospital based training in the diagnosis and management of childbirth complications.

Homebirth midwives (direct entry midwives including CPMs) try to trade on the reputation of other midwives. However, homebirth midwives have grossly deficient education requirements (they can obtain their education by correspondence course) and grossly deficient training, lacking any training in the diagnosis and management of complications. American women need to understand that American homebirth midwives cannot meet the requirements to be licensed in ANY first world country.

Lake also neglects to mention that American homebirth midwives are currently hiding their safety statistics from the public. The Midwives Alliance of North America (MANA) the trade union for direct entry midwives has been collecting extensive statistics on the safety of homebirth since 2001. Those statistics have been publicly offered to anyone who can prove they will use them for the “advancement of midwifery”. Even then you must sign a legal non-disclosure agreement preventing you from revealing any data to anyone else. It does not take a rocket scientist to suspect that MANA is suppressing its OWN data because it shows that homebirth with a direct entry midwife increases the risk of neonatal death, and possibly the risk of brain damage as well.

In order for women to make an informed decision about homebirth, they need to know the truth about homebirth. And the truth is that all the existing scientific evidence to date shows that homebirth increases the risk of neonatal death, that American homebirth midwives cannot meet the licensing requirement for any country in the industrialized world, and that the homebirth midwives trade union is hiding 7 years of their own data on the safety of homebirth.

Ricki Lake should stop spreading misinformation about homebirth, should stop claiming that homebirth is as safe as hospital birth, and should use her influence to demand that homebirth midwives release the safety data that they are hiding.