A guest post from a registered nurse (RN):

I used to be an assistant to a lay midwife who delivered babies in her own home. I was so ignorant, and I didn’t KNOW I was ignorant! The midwife didn’t recognize her ignorance either.

I really had no idea of the difference in education between CNM, CPM, and DEM. This particular midwife is completely self-taught, a “granny” midwife with no medical background. When I was assisting her, she delivered approx. 200 babies a year. She did not have OB back-up, but she did have a certain amount of respect from the local doctors and hospital, who accepted her transfers without hassle. That respect was probably because she at least didn’t try to do vaginal births at all cost and she did not wait too long to transfer. Also some respect simply because of her persona. She makes you feel like she is in charge, and just knows things. I’ve heard local medical personnel make remarks like “K really has a knack and intuition for midwifery, doesn’t she?” This persona is what makes the mothers feel safe with her. At first I thought she “knew” everything too. But as I worked with her, I began realizing that it wasn’t true. I tried to change how some things were done, but the lay midwife became upset. No one was allowed to threaten her little kingdom! So I left.

I became a registered nurse, and got a job working in a Labor and Delivery unit. Then I began to understand how little I really knew, and how deficient and downright dangerous the lay midwives are! As has been pointed out on your blog so often, when you are ignorant you don’t KNOW you are ignorant!

I used to believe what the midwife said, that the apprenticeship model is just as valid as formal education. She used to say “I would much rather have an experienced midwife (DEM) attend me than a CNM just out of school.” I, of course, thought that made complete sense. But that is complete BS, because you have no idea how the DEM practices or how accountable she is. The new CNM has real medical professionals looking over her shoulder until she has the necessary experience to practice safely.

This is why there should be uniform standards of education and practice for ALL midwives. The following paragraphs are very specific examples of direct entry midwifery practices as I experienced them.

She accepts anyone who wants to VBAC, regardless of the client’s history. I never heard her asking anyone what type of uterine incision she had. It wasn’t until I became an RN that I learned a woman should never TOLAC after a classical incision, I doubt she even knows that. Now I’m amazed that we never had a rupture that I know of (during the time I assisted her at least).

There’s no understanding of hemodynamics, and what acute blood loss can do to the body. What are signs of too much blood loss? Um, we didn’t know. We took one blood pressure after delivery and that was it. No pulse, no O2 sat. I didn’t know what a dangerously low blood pressure was until I was in nursing school. I knew how to take vital signs, but I had no idea how to interpret them. I didn’t know what they would look like when a woman was hemorrhaging. I don’t think the midwife knew either because she never took vital signs. So when did we transfer for hemorrhage? When the woman was lying in a pool of blood and passing out. Estimated blood loss? No idea. We estimated it in terms of a little, medium, a lot. No idea how many mLs. This is why it is easy for me to believe that the midwives in Australia didn’t recognize the signs of acute blood loss in Caroline Lovell’s case. Lay midwives are not trained professionals, they don’t know!!!

She didn’t know how to do perineal repairs. She always told the women to “keep their legs together for several weeks” and the lacerations would heal just fine. Once or twice I saw her put several random stitches in the perineum, but never any vaginal repair. She had no idea how to do it; therefore it would heal “just fine”. Not enough education!!

Prenatal visits consisted of a blood pressure check, FHT with doppler, manual palpation of fundal height and estimation (no actual measurement), and external position check. No weight check. Cervical exams were done close to term. A primip was sent to her PCP for a blood type to check RH. No other blood work was ever done, unless a mom specifically asked for it. Most moms were routinely given oral iron to cover any potential anemia, and they all got calcium and a prenatal vitamin. There were no urine checks for protein, no GBS testing, and no testing for gestational diabetes. No ultrasounds, unless the midwife had a question about position or the woman had a prior infant with an anomaly. Of course she had mostly low-risk women. They were “low-risk” because she didn’t check for any conditions that might make them high-risk, or really even know what conditions are high-risk. Not enough education!

So we didn’t have any gestational diabetics (because we didn’t test for it), of course we didn’t have to follow any newborn glucoses either. But of course, we had no idea that newborns might have a problem with their glucose because we had never learned about that!

She did no newborn exams, no newborn vital signs. She never laid a stethoscope on the newborns at all, nor checked their temperatures. And even if she had, she didn’t know normal parameters for newborn respiratory rates. Most babies got apgars of 9/10, some even 10/10. No babies got any eye prophylaxis or Vit K. There was no breastfeeding support offered.

There was no continuous fetal monitoring during labor, only doppler checks every once in a while. She did no charting at all, so there were no scheduled time intervals by which checks must be done, just when she happened to think about it. I had no idea about decels or fetal distress. I thought if you put a Doppler on the belly and the FHT are below 120, the baby is in distress. I didn’t know there was such a thing as late decels or what they meant. In second stage the baby was monitored once or twice. When we had a baby with low apgars, it was always “with no warning”, and “the baby was fine all through labor”.

She was not NRP certified nor was she even CPR certified. She carries oxygen and an infant bag with mask, and attempts resuscitation if needed. It impresses the parents, but isn’t much good actually. Now I have a NICU resuscitation team 30 seconds away from each delivery and I realize how inadequate our efforts were. Not enough training and education! Her assistants now are not required to have even CPR training and have no idea how newborn resuscitation is done.

She attempted external versions for breech and transverse lie. She delivered breech and twins. She had no idea of whether twins are di/di or not, nor any idea of the significance of that.

She used “black market” Pitocin for postpartum hemorrhages. But she didn’t stick to postpartum use. She gave it to augment stalled labor. How could she do that, without IV access? Simple, she gave it subcutaneously, in small amounts. And it worked. Now I’m appalled, aghast, at how recklessly dangerous that is without CEFM. I had no idea! Not enough education!!! There are many other OOH midwives doing the same thing.

She never used sterile gloves, or set up a sterile field for deliveries. Sterilization of instruments consisted of wiping them off with alcohol.

This midwife’s clientele is almost exclusively Amish. She practices near one of the largest Amish communities in the US in a state where lay midwives operate in a “gray area” legally. She likes it that way because the Amish women don’t question her, trust her implicitly, and will not pursue litigation or repercussions of any kind. They call her for any kind of medical questions they have, even outside of women’s health, and she freely dispenses medical advice over the phone without seeing the patient in question. Sometimes her advice even contradicts a doctor’s advice. . .guess whose opinion carries the most weight?

The only way to make homebirths safer is abolish the CPM and DEM, and require all midwives to be CNMs. I do think the Amish should be able to have an OOH birth option, as this is more compatible with their lifestyle. They are not doing homebirths to be crunchy or because they believe in vaginal births at all costs. They have never even heard of the “Business of being Born”. But they do deserve better care than they are getting. Every woman deserves professional medical care!!

I am humbled by the profound love that James Titcombe has shown for his son Joshua.

James and his wife Hoa lost their son to midwifery incompetence (Joshua’s easily preventable, tragic hospital birth death). According to an National Health Service investigation quoted by The Independent:

Joshua died in November 2008, nine days after being born at the Furness General Hospital, part of the University Hospitals of Morecambe Bay NHS Foundation Trust. An inquest in 2011 said that staff at the hospital failed to spot a common infection, and that he would have stood an 80 per cent chance of survival if antibiotics had been delivered in the hours after his delivery.

The pain and frustration that James Titcombe deals with must be immense. The NHS initially refused to investigate, but James continued to advocate for Joshua. When he decided to take a break from his years of pressing for an investigation, he was treated with unspeakable contempt. According to The Independent:

The family were left deeply hurt on two occasions after seeing internal email exchanges between Trust staff. One followed an email from Mr Titcombe in June 2010 saying he would be stepping back from his inquiries after “becoming extremely distressed and anxious” about the investigations progress.

Informing the Trust’s head of midwifery of the email, the Trust’s customer care manager wrote: ‘Good news to pass on re [Mr D]’, and received the reply: ‘Has [Mr D] moved to Thailand? What is the good news?’

In another email from August 2009, later seen by Mr Titcombe, a discussion of a midwife’s statement to the Nursing and Midwifery Council (NMC) concerning the circumstances of Joshua’s death was subject lined: “NMC shit”.

But James did not give up. He fought on for Joshua and ultimately he and Hoa received an apology from NHS for not investigating Joshua’s death back in 2010, and an apology for the inappropriate emails.

James has continue to advocate on behalf of other babies, so no parent will have to endure the preventable death of a baby, a refusal to investigate it, and the contemptuous treatment that followed it.

UK midwife Sheena Byrom and her colleagues are familiar with James’ efforts and apparently consider him ever so tiresome.

Byrom and colleagues were having a public Twitter confab on the use of social media during and after birth (just like nature intended, no doubt). Byrom tweeted that hospital policies appeared to be dictated by risk and “all this talk about risk. Not comfortable with it.”

James entered the Twitter stream to point out that childbirth is indeed quite dangerous. He should know. His son died as a result of an infection acquired during birth.

A chilling response from Byrom and colleagues follows:

Highlights include:

oh James-don’t let’s get on that roll again …

and:

getting out of bed in the morning has risks http://homebirth.org.nz/magazine/article/climbing-trees/

Yes, James, how could you be so tiresome, always going on about the risks of childbirth and the babies who die as a result? Sheena is so over that.

Sheena ought to be ashamed of herself for the chilling way that she dismissed the father of a baby who died as a result of midwifery incompetence. But that would involve insight, compassion and a sense of responsibility, something in woefully short supply among UK midwives.

How can women trust “professionals” who dismiss a dead baby as a troublesome distraction from the agenda of promoting midwifery?

And how can women trust “professionals” who are aggressively close minded. When I posted a link to my piece debunking the article that Sheena cited, she responded thus:

don’t read your foolish, dangerous blogs, you are blocked.

and:

It’s almost as if Sheena and colleagues fear that by reading my blog, they might learn something they did not want to know. And that could be “toxic and dangerous” to them (who cares about babies and women who might be saved?).

Byrom’s contemptuous dismissal of James Titcombe, a father whose son died of midwifery incompetence, who was forced to endure a refusal to investigate his son’s death, and subject to chilling emails that treated his dead son as an inconvenience, is both outrageous and disgusting.

Her refusal to read my blog is indicative of the close mindedness of UK midwives who prize validation above scientific evidence, process above outcomes, and midwifery income above the lives of babies and mothers.

Sheena Byrom, have you no shame?

Oh, wait, you’re a UK midwifery leader, so of course you don’t.

When my husband and I were first married, we didn’t have much money, and, therefore, didn’t have a lot of choices in housing. Our apartment, while conveniently located, had certain problems including a cockroach infestation. Every morning when we turned on the light in the windowless kitchen, dozens of cockroaches would scurry out of the light back into the darkness.

I hadn’t thought about that daily occurrence in many years until it recently came to me that birth bloggers are like cockroaches. They, too, gather in the darkness and scurry away when the light of science is shined upon them. That’s because they KNOW that they cannot defend their claims against actual scientific evidence.

Unlike cockroaches, however, birth bloggers can turn off the light when they are exposed. How?

1. The natural habitat of the birth blogger is her own blog, where she decides how much light, if any, is shed on actual scientific evidence.

2. Birth bloggers almost never stray outside their blogs because they will be crushed in the light of scientific evidence. Hence, they never attend mainstream conferences, they never speak at medical conferences, are never invited to sit on expert panels, are never invited to testify in malpractice cases, and are not considered “experts” by anyone but themselves.

3. Birth bloggers invite visitors to their natural habitats, but protect themselves from the light of scientific evidence by deleting and banning any commentors who dare to question them or to present evidence that they chose to ignore.

4. Birth bloggers thrive in the darkness of ignorance and gullibility of their readers. Anyone with actual scientific knowledge would laugh at them.

5. Birth bloggers, like cockroaches have highly evolved defense mechanisms. Birth bloggers are evidence-resistant. They start from a conclusion and work back to cherry pick evidence to support it, while ignoring the larger body of evidence that debunks their conclusions.

6. Birth bloggers find support in numbers. They proliferate like cockroaches and no sooner is one crushed by the weight of scientific evidence, then another repeats the same lies that the first couldn’t rebut.

When we shined the light of science on the hideous rupture rate in Jen Kamel’s VBACFacts group, she ruthlessly purged the group, leaving her followers in the dark about the truth. When we shine the light of science on Rebecca Dekker’s assertion that her claims are “evidence based,” she deletes them and bans commentors, leaving her followers in the dark about the truth. The Lamaze blog Science and Sensibility routinely vets comments to be sure that their followers are left in the dark about real scientific evidence. Indeed, there is not a birth blogger that I am aware of who doesn’t routinely ban and delete when presented with scientific evidence.

Why are these birth bloggers afraid of the light? Because, like cockroaches, they know they will be easily crushed when people can see them for who they are: lay people who promote and profit from pseudoscientific nonsense.

How can women protect themselves from the infestation of birth bloggers? It’s pretty simple.

Never trust the information you get from a birth website that heavily moderates, deletes and bans. It means that, just like cockroaches, they are hiding in the dark. They wouldn’t need to heavily moderate, delete and ban if what they are write were true.

One of the favorite memes of advocates is that natural childbirth is “evidence based,” while obstetricians ignore scientific evidence. Childbirth blog, websites and message boards slap “evidence based” over whatever nonsense they dream up, and figure that the gullible public will look no further.

A good rule of thumb for anyone researching childbirth is this: if a natural childbirth website calls itself “evidence based,” it almost certainly purveying pseudoscience dressed up as science. The website of cardiology nurse Rebecca Dekker, Evidence Based Birth is a prime example. As the saying goes, you can put lipstick on a pig, but it’s still a pig, and in the world of childbirth, “Evidence Based Birth” is a big fat pig covered with lots of lipstick.*

How can you tell the difference between science and pseudoscience dressed up as science? This image from I fucking love science lays out the general principles.

The primary difference between science and pseudoscience is a willingness to change based on new evidence. Pseudoscience, in contrast, starts with a conclusion and defends it regardless of the evidence.

Rebecca Dekker starts with the premise that the tenets of natural childbirth are true and looks for evidence that confirms those tenets. She ignores evidence that does not support natural childbirth, and is not above deliberately misleading readers by posing one question, but answering another.

Her recent piece on waterbirth, Evidence on the Safety of Water Birth, is a classic in this genre. Dekker starts with the premise that waterbirth is safe and cherry picks evidence to support that claim while ignoring or inappropriately dismissing evidence that shows the opposite.

What is waterbirth? It is the practice of giving birth a plastic pool of water that is inevitably fecally contaminated. It is the equivalent of giving birth in a toilet, and has similar risks, including the risk that the baby will breathe in or swallow the fecally contaminated water.

The American Academy of Pediatrics’ Committee on Fetus and Newborn in conjunction with the American College of Obstetricians and Gynecologists has recently updated its position on waterbirth. Nothing has changed since the previous edition published in 2005, except in the intervening years more cases of perinatal death and injury have been reported.

Some of the reported concerns include higher risk of maternal and neonatal infections, particularly with ruptured membranes; difficulties in neonatal thermoregulation; umbilical cord avulsion and umbilical cord rupture while the newborn infant is lifted or maneuvered through and from the underwater pool at delivery, which leads to serious hemorrhage and shock; respiratory distress and hyponatremia that results from tub-water aspiration (drowning or near drowning); and seizures and perinatal asphyxia. (my emphasis)

But, hey, that’s just the way that the American Academy of Pediatrics’ Committee on Fetus and Newborn and the American College of Obstetricians and Gynecologists assess the scientific literature. Cardiology nurse Rebecca Dekker thinks she knows better.

Her piece contains lots and lots and lots of words, but her conclusion is pretty simple. The evidence that currently exists is less than the highest quality evidence.

Duh!

The AAP and ACOG are well aware of that. They are invoking the precautionary principle. What’s the precautionary principle?

According to Wikipedia:

The precautionary principle … states that if an action or policy has a suspected risk of causing harm to the public or to the environment, in the absence of scientific consensus that the action or policy is not harmful, the burden of proof that it is not harmful falls on those taking an action.

In other words, in the absence of high quality evidence that waterbirth is safe, it should not be standard care. AND it is up to the proponents of waterbirth to provide that high quality evidence before waterbirth can be recommended.

But Dekker completely ignores the precautionary principle in her conclusion.

According to Dekker:

Based on the data that we have, waterbirth is a reasonable option for low-risk women during childbirth, provided that they understand the potential benefits and risks. If women have a strong desire for waterbirth, and there are experienced care providers who are comfortable in attending waterbirths, then at this time there is no evidence to deny women this option of pain relief.

Simply put, the AAP and ACOG believes (in conjunction with Dekker) that there is no high quality evidence to support waterbirth, and a growing body of lower quality evidence that waterbirth kills babies who breathe in the fecally contaminated water or swallow it during birth. Dekker starts with the conclusion that waterbirth must be safe, dismisses the existing evidence on the deaths that resulted from waterbirth, and asserts that it must be considered safe until it is definitely proven to be deadly. Dekker’s claim about the safety of waterbirth isn’t evidence based; it’s her opinion.

The same thing goes for nearly everything on her site. That is presumably why Dekker isn’t spending any time speaking in any venue where she could educate pediatricians or obstetricians about their purported errors in evidence interpretation. She knows she’d be laughed off the stage. She isn’t writing for physicians or scientists, either, because they would eviscerate her claims in short order. She writes for lay people who aren’t capable of assessing the validity of her claims and, in many cases are merely looking for justification to ignore the advice of pediatricians and obstetricians.

A more accurate moniker for her website would be “Rebecca Dekker’s Opinion on Birth,” but who is going to take that seriously? Instead, she calls it “Evidence Based Birth.” Dekker can put lipstick on a pig of a website, but it’s still a pig.

 

 

*Dekker basically admits this in her website disclaimer:

The information presented here does not substitute for a healthcare provider-patient relationship nor does it constitute medical advice of any kind… The opinions expressed in this blog are strictly the author’s personal opinions … The information on this blog may be changed without notice and is not guaranteed to be complete, correct, timely, current, or up-to-date…(my emphasis)

Ideological consistency has never been a hallmark of the natural childbirth movement, (childbirth is painful/no, it’s orgasmic; I didn’t need any pain relief/I couldn’t have done it without the birth pool; I am a warrior birth goddess who can withstand any amount of pain/I can’t bear to have a heplock), but it often seems that the inconsistency reaches its apogee around the issue of C-sections.

The phrase “too posh to push” suggests that choosing a C-section (for breech, after a previous C-section, without a medical indication) is the easy way. It implies that women who choose C-sections are lazy and can’t be bothered with the hard work of pushing a baby out through the vagina.

Yet ask a natural childbirth advocates why she fears a C-section and will go to extraordinary lengths to avoid one, and she’ll tell you that it is because C-sections are so painful, and the recovery is so long and difficult that it compromises the ability to bond to and care for a newborn.

So which is it? Are C-sections easy or are they hard.

Lactivists seem to have a similar problem with the issue of breastfeeding. They can’t seem to decide whether breastfeeding is easy (I did it because it is soooo convenient; you never have to mix formula; it’s always the right temperature and amount) or it is hard (I never gave up even though my nipples were bleeding, my baby was screaming from hunger, I nursed every 2 hours and pumped every hour in between).

Lactivists have a similar problem with formula. It’s easy (don’t give women formula samples or they’ll use them because it’s easier!) or hard (all those bottles to wash! it’s so expensive!).

So which is it? Is breastfeeding easy or is it hard?

My theory is that the real dichotomy for natural childbirth advocates isn’t easy/hard, but right/wrong. Vaginal birth is “right” and C-sections are “wrong” and they will say whatever it takes to shame women into doing things the “right” way. So choosing a C-section is sometimes easy, sometimes hard, but always wrong. Similarly choosing to formula feed is sometimes easy, sometimes hard, but always wrong.

In both cases, advocates will say whatever it takes to sway the listener since advocates couldn’t care less whether a C-section or formula is easy or hard for a particular mother. They don’t care about her and they don’t care about her baby. They care only about themselves and their desperate need to validate their own choices by having everyone else mirror them back.

The truth is that individual women have individual circumstances that make individual choices easy or hard for them. Natural childbirth and lactivism have no room for individuality; they are all about conformity. Hence the ultimate ideological inconsistency: childbirth is natural, but you must read books, websites, hire a childbirth educator to teach you and a cheerleader (doula) to encourage you, use a birth ball, live blog and live tweet the event, hire a photographer and post the video on YouTube … just like they did in nature.

According to Peggy O’Mara, Editor of Mothering.com:

One source that does not have a conflict of interest is the Cochrane Collaboration, internationally recognized as the highest standard in evidence-based healthcare reviews. When Cochrane compared the midwifery model of care to other models of maternity care, they concluded “that most women should be offered midwife-led continuity models of care…” Cochrane also says that there is no strong evidence to favor either planned homebirth or hospital birth.

O’Mara is wrong.

O’Mara is not alone in her reliance on Cochrane Reviews. Lay people love Cochrane pregnancy and childbirth reviews. They always include easy to understand plain language summaries and are generally written by volunteers, many with an natural childbirth ax to grind.

To understand why Cochrane Reviews, particularly childbirth reviews, are often a poor standard of evidence, it helps to understand what Cochrane Reviews are and what they are not. Cochrane Reviews are systematic analysis of randomized controlled trials on a particular topic. Randomized controlled trials (RCTs) are trials in which two treatment options assigned randomly to two groups and in ideal cases neither the patient nor the scientist knows what treatment the patient received (double blind). RCTs are considered the “gold standard” in scientific research.

But what happens when RCTS are either unfeasible or unethical or both? For example, it is unethical to ignore women’s preferences and randomize them to home or hospital birth. Does that mean that it is impossible to investigate the relative safety of home and hospital birth? No, it does not. While RCT’s are at the top of the hierarchy of research methods, there are many forms of research including cohort studies, case-control studies and case series, among others.

But Cochrane Reviews do not consider these other forms of evidence, not because they are unreliable, but because they are outside the scope of Cochrane Reviews. That’s fine, but then they go ahead and do something that is not fine at all. When there are limited RCT’s or poor quality RCT’s, they analyze them anyway as if such an analysis could provide accurate data. Since it is unethical to perform an RCT on homebirth, there should be NO Cochrane Review of homebirth. Instead there is a review that is nothing more than garbage.

Here’s what the Cochrane Review of homebirth showed:

Main results

Two trials met the inclusion criteria but only one trial involving 11 women provided some outcome data and was included. The evidence from this trial was of moderate quality and too small to allow conclusions to be drawn. (my emphasis)

Authors’ conclusions

There is no strong evidence from randomised trials to favour either planned hospital birth or planned home birth for low-risk pregnant women.

No, there is no evidence PERIOD. Therefore no conclusion can be drawn PERIOD.

The bottom line is obvious. When it is unethical to perform RCTs or the RCT’s that exist are small and underpowered, a systematic review of RCTs is worthless. Hence the Cochrane Review of homebirth is useless.

Let me amend that: by publishing a “systematic review” that includes only 11 women, the Cochrane Childbirth Group makes it clear that they are willing to publish garbage if that is the alternative to publishing nothing at all.

Slate has published a terrific piece about C-sections written by Dr. Chavi Eve Karkowsky entitled Sorry You Were Tricked Into A C-section; What disapproving friends don’t understand about cesarean births.

Dr. Karkowsky perfectly captures the disdain and pity faced by women who have undergone a C-section:

You’d think any woman who has recently had major abdominal surgery and has a newborn to care for would have enough to deal with, but too often there’s more… A woman who has had a cesarean birth gets comments from her friends—online friends, IRL friends—mostly congratulations, but also messages of regret…

…[H]er friends and relatives tell her, outright or through subtext, that she must have been snookered. She was fooled and then underwent some shady butchery…

Dr. Karkowsky goes on to explain why these well meaning friends and relatives are often wrong. C-sections save tens of thousands of live in this country alone, each and every year.

I enter an operating room to do an unscheduled cesarean birth with gratitude… How lucky are we—how lucky is this mother and this baby, but also, selfishly, me—that we have another way. How lucky that I walk into that operating room reasonably sure that all three of us will come out, breathing, at ease.

So where did these “well meaning” friends and relatives get the idea that C-section are unnecessary? If you want to know the answer, follow the money. The money will lead you to an entire industry devoted to demonizing C-sections for its own economic benefit: the natural childbirth industry.

“Big Birth” is a multi-billion dollar industry, comprised of midwives, doulas, childbirth educators, and lay people who offer dubious services like placenta encapsulation. They have industry foundations and groups, complete with lobbyists and public relations people, devoted to promoting the economic well being of their members. Recognizing that it is rather crass to straightforwardly promote your own employment prospects, “Big Birth,” like other industries, presents itself as piously concerned with what is best for its customers. Big Oil just wants its customers to have access to the “best” method of heating their homes; Big Pharma just wants its customers to have access to the “best” medications; and Big Birth just wants its customers to have access to the “best” form of birth, vaginal birth.

There are plenty of goods and services that Big Birth can provide, but there are two that it cannot and both, therefore, threaten its economic bottom line. Those services are epidurals and C-sections and both are demonized with passion.

“Big Birth” demonizes epidurals despite the fact that there is no evidence – zip, zero, nada – that pain relief in labor is anything but beneficial for those who want it. But the effort to demonize pain relief in labor (“It’s good pain!” “Real women embrace the pain!” You won’t bond with your baby if you don’t feel the pain!”) pale in comparison to the frantic efforts to demonize C-sections.

C-sections dramatically cut into the profits of Big Birth so they must be caricatured as unsafe, unnecessary and positively harmful. When friends and relatives tell a C-section mother “outright or through subtext, that she must have been snookered. She was fooled and then underwent some shady butchery,” they are channeling the propaganda of Big Birth. Big Birth has been so successful in promoting their own economic self-interest, that their propaganda has become “conventional wisdom,” despite an almost complete dearth of scientific evidence to support their claims.

Birth Birth has been aided immeasurably by two factors. The first is the alliance with those who wish to save money by denying care, whether that care is necessary or not. Cesareans cost more than vaginal birth. Big Birth provides public relations cover for those who want to reduce the cost of obstetric care. Demonizing C-sections serves the economic bottom line of cost cutters and of Big Birth.

The second factor is that the late Marsden Wagner, MD, a diehard partisan of Big Birth, managed to gain a position of influence in the World Health Organization back in the 1980’s. Dr. Wagner almost single handedly engineered the now discredited WHO claim that the optimal C-section rate is between 5-15%. The claim was withdrawn in 2009 when the WHO acknowledged that there was no evidence and there HAD NEVER BEEN ANY EVIDENCE to support any optimal C-section rate, let alone the one decreed by Dr. Wagner. Indeed, international data shows that C-section rates under 15% are accompanied by unacceptably high levels of maternal and perinatal mortality.

Apparently the WHO was embarrassed by the way that it had been snookered and therefore buried its retraction in the middle of a large document leaving most people unaware of the retraction. Hence the claim continues to be repeated despite the fact that it was never true and has since been disavowed.

Are there too many C-sections? Possibly, and we should always be researching ways to lower C-section rates as far as we can without compromising safety. But the fact is that the countries with the best maternal and perinatal mortality rates have an average C-section rate of 22%, and very high C-section rates (up to 42% or more in the case of Italy) are completely compatible with excellent maternal and perinatal outcomes.

Some people have been snookered, but it isn’t the mothers who give birth by C-section. It is those who promote the idea that most C-sections are unnecessary, done for doctor convenience and harm mothers and babies, who have been fooled.

Follow the money. Those whose bottom line is threatened are the most vocal in demonizing C-sections. Big Birth is a huge industry, and like any industry, we should take their claims with not simply a grain of salt, but an entire shaker.

I was at a conference this past weekend where a famous astrophysicist explained that being a practicing scientist means constantly trying to figure out how your own claims are wrong. It is easy, all too easy, to look at some data, draw a conclusion and stop there. But science demands that we look at all conclusions, even our own conclusions, to determine if there is an alternative explanation for the data we have in hand. All too often, there is.

That’s why the Karolinska Institute’s decision to create a publicity campaign for a new paper on the possibility that C-sections might lead to epigenetic changes in newborn DNA is thoroughly irresponsible and violates the fundamental principles of science.

The paper is entitled Cesarean delivery and hematopoietic stem cell epigenetics in the newborn infant: implications for future health?. Let me tell you exactly what it shows:

NOTHING!

It is a tiny set of preliminary observations, without demonstrated reproducibility, with no evidence provided that it is clinically relevant in any way.

To give you an idea of just how preliminary it is, and just how irresponsible it is to promote it, imagine if I published the following study:

Cesarean delivery and newborn blood type: implications for future health?

This was an observational study of 64 healthy, singleton, newborn infants (33 boys) born at term. Cord blood was sampled after elective CS (n = 27) and vaginal delivery. Blood type was determined in the standard fashion.

Results
Blood type of infants delivered by CS was more likely to be O+ than blood type from infants delivered vaginally. In relation to mode of delivery, a antigen specific analysis of multiple antigens (Duffy, Kell, etc.) showed difference of of 10% or greater in a number of different antigens.

Conclusion
A possible interpretation is that mode of delivery affects blood type.

Ridiculous, right?

We know that mode of delivery has no impact on blood type, but it is completely possible that if we looked at the blood types of 64 infants (27 born by elective C-section), we might get these exactly results simply by chance.

Why might we get these results by chance?

• We looked at too few babies
• We never checked the background rate of these findings
• We assumed that differences of 10% were statistically relevant
• We failed to look at the difference over time by sampling blood type before birth and at multiple intervals after birth

All these deficiencies would apply to the study of methylation of newborn DNA, plus:

The authors have not demonstrated that DNA methylation is a proxy for epigenetic changes

The result is that their paper shows an observed difference between tiny groups with no evidence that the observed difference has any relevance to anything at all.

There is nothing wrong with publishing a paper that simply relates observed differences. That is often what basic science is about. But there is something very wrong with speculating on the meaning of those difference without any evidence to support the speculation. And there is something grossly irresponsible about publicizing an observed difference that may simply reflect chance.

I understand that it is very difficult to get funding for basic science research. And I understand that implying that your basic research has relevance to a current area of speculation might improve your chances of funding. But trumpeting as finding of essentially nothing to a public by implying that it means something is unethical. It only serves to scare people and to undermine trust in the sciences when better quality data inevitably reveals something entirely different.

Responsible scientists should not publish data until they have reproduced it and until they have carefully considered and rejected all possible reasons why their conclusions are wrong. That’s science; this paper, in contrast, is just self-serving publicity.

I guess it’s progress of a sort.

As the evidence mounts that homebirth kills babies who didn’t have to die, advocates are switching gears from denying the increased risk of perinatal death to rationalizing it.

The latest effort, greeted rapturously in the homebirth community, is Climbing Trees by obstetrician Alison Barrett.

was one of those kids who loved to climb trees…

I want to be clear: climbing trees was not, to me, about taking risks. There was nothing about tree climbing that felt risky, in fact, it felt very safe, to be cradled in the canopy of a tree…

Climbing trees is a metaphor for homebirth.

Some people think children should not climb trees. They’ve banned it in school yards. Today some might claim that my parents were irresponsible. Perhaps they would have reported my mother …

There are people who believe that risk shouldn’t be allowed in childbirth either. Since it involves an unborn child, who cannot consent, parents should be made to do the right thing…

So Barrett acknowledges that homebirth carries the risk of death, just like climbing trees carries the risk of death. The important issue for her is that the benefits outweigh the risks:

When I look back, I am sure that climbing trees gave me some immeasurably important gifts. One was a belief in my own body. I’m not a star athlete; I don’t consider myself particularly stoic, or brave, or over-confident. That belief in my own body served me well later on during the birth of my children, and in attending the births of others…

Let’s leave aside for the moment the fact that that argument can be made for any practice, no matter how dangerous. Perhaps drunk driving gives you a thrill and a feeling of self-confidence. That does not rationalize drunk driving.

But the real problem with Barrett’s argument is not its weakness, but its inadequacy. Homebirth is not like climbing trees. It is like climbing trees with a baby in your arms; and the baby makes the risk calculus very different.

1. Carrying a baby in one arm makes climbing a tree much more dangerous. It reduces maneuverability, changes balance, makes it difficult to get a strong grip, putting the climber at much greater risk of falling. Similarly, giving birth to a baby entails many life threatening risks to the mother that simply don’t apply when she is not pregnant.

2. You could climb the tree safely, but drop the baby out of the tree to its death on the ground below. I suspect that we would all agree that climbing a tree with a baby in your arms would be a reckless parenting decision, no matter how much satisfaction it would give the mother to show her child the view and no matter how much pleasure the view might give to the baby. In many situations, homebirth is a reckless parenting decision because it is the baby who is in far greater danger than the mother.

3. Climbing a tree isn’t a metaphor for homebirth. It’s a metaphor for birth itself. Childbirth inevitably carries risk. Regardless of what tree you climb, or where the tree is located, there is always a risk for the climber. But you can make the climb more or less dangerous depending on the conditions. Climb in a hurricane, and you increase the risk. Climb a dead tree and you increase the risks. Climb with a baby in your arms and you’ve dramatically increased the risk. Similarly, give birth in a birth center far from the hospital and you increase the risks. Give birth at home and you increase the risks even more.

4. Climbing the tree holding a baby increases the risk, but climbing a tree holding two babies increases the risk even further. Similarly, giving birth to twins at home (or a breech baby, or after a previous C-section) increases the risk even further.

5. The risk of climbing is completely independent of whether you feel safe while climbing. It makes no difference if you feel safe inching out along dead branches. It makes no difference if climbing to the top of a redwood doesn’t frighten you. And it certainly makes no difference if you trust trees. The risk exists independent of the views of the person who undertakes it. That’s why the claim that feeling “safe” at homebirth is utterly irrelevant. Your safety and risks have nothing to do with how you feel about them.

I’m grateful that Barrett acknowledges the risk of homebirth. Homebirth kills babies who didn’t have to die and that is irrefutable. I find her effort to rationalize that increased risk to be deeply flawed, however. She wants to imply that the increased risk of death at homebirth can be justified by the personal growth experienced by the mother. She conveniently ignores that while the mother is knowingly adopting the risk, the baby is not and the baby is the one with the most to lose.

Homebirth isn’t like climbing trees. It’s like climbing trees with a baby in your arms. It’s the baby that makes the risk unacceptable for most women, not the trees.

This blog affords me a bully pulpit and today I’d like to use to focus on an issue close to my heart.

As a mother of two children with disabilities, I was spitting mad when I read the Facebook post above.I have some advice for Gina Crosley-Corcoran, who wrote it:

STOP IT!!

Your children do not exist to make you look good to the world, and their struggles are not an opportunity for you to publicly feel sorry for yourself while violating their privacy.

Educate yourself about Asperger’s. Violent behavior is NOT a symptom of Asperger’s, but frustration is. If you had to navigate the world without being able to understand the social cues that everyone else understands so easily, you might be frustrated, too.

Your “Aspie son” is NOT his disability and should not be identified as if his disability were the most salient fact about him. He is your son and like all your children, he deserves your love, respect and best efforts to help him reach his full potential.

The next time you get the impulse to publicly complain about your child’s disability, exercise the control you find so lacking in him and stop yourself.

Try a little thought experiment. Consider how my post makes you feel. Probably not very happy, even though I am a stranger with whom you have no personal relationship. Now extrapolate to your son. You are the center of his world, the object of his love, his most important source of approval and support. How much worse will he feel when he eventually reads your scathing condemnation of him?

A child’s love and trust is a very precious thing. Don’t abuse it. And, please, please, please do not confuse your child with his disability. If you are worn down by coping with it, get psychological help for yourself, but don’t give into the impulse to soothe yourself by publicly humiliating him.