The readers of The Skeptical OB are the best, most interesting, most articulate folks on the web. Here’s a guest post from reader and frequent commentor Olga Mecking. Olga is a Polish woman living in the Netherlands with her German husband and three trilingual children. She is a translator, trainer in intercultural communication and writer. She blogs at The European Mama, a blog about her experiences of living and raising children abroad, culture, language and parenting.

For many reasons, the first time I was pregnant, I received care in three different countries, including my native Poland, Germany (where my daughter was ultimately born) and the Netherlands. My first child was born in Germany after a long and grueling 38 hours of labour.

When I got pregnant the second time, I was living in the Netherlands and received my pregnancy care from Dutch midwives. For reasons that made sense to me at that time, I wanted to have a homebirth and felt supported in this decision. I figured that the Netherlands are the perfect place for giving birth outside of the hospital. The idea is that birth isn’t an illness and doesn’t require a special doctor. OBGYNs work in hospitals, and only care for high-risk pregnancies. If a midwife finds out that something is wrong, she will transfer the woman to a doctor.

My second pregnancy went very smoothly, if I forget about the horrible heartburn. The midwives told me it’s normal and so I didn’t get any medicine because I was afraid I’ll hurt my unborn child. However, they did regular urine tests, 3 blood tests and as many ultrasounds.

Al the time, I was scared of having another hard birth. My first daughter weighted 3600 grams. It’s nothing out of the ordinary but for a petite woman like me, she was huge. I felt torn between my desire to have a peaceful, calm homebirth and having immediate access to a C section if it was necessary or I chose to have one. In the end, I went with the homebirth, but when my water broke one day after my due date, the midwife came to check on me and told me that I have to go to the hospital and will be cared for by a second-line midwife- one that works in the hospital and takes on more complicated cases. As we are expats, we didn’t have anyone to take care of our daughter during that birth and we took our big girl with us. No one batted an eyelash though, they gave her a bed and some toys.

My midwife brought us to the hospital and disappeared because she was not allowed to care for me anymore. The new midwife and her assistant monitored my daughter’s heartbeat. I wanted at least to have the freedom to move around and they agreed to insert an internal monitor that was attached to my baby’s head, and it didn’t restrict my movements. During transition, I asked for an epidural- I was in pain and didn’t know it was transition. The midwife said that she’ll get it and disappeared. She only came back after I called her in and told her I needed to push. It would have made a world of a difference if she told me that it’s going to be over soon. But my little girl was born without any problems just a few pushes later. Because there was meconium in the water, they kept us in the hospital for the night.

When we came home, we were visited by a special maternity nurse, called kraamverzorgster in Dutch. While I was skeptical of letting a stranger into my house for 8 hours a day for a whole week, she proved to be a huge help. She cleaned the floor, prepared my favourite tea, made our bed and took care of my big girl while I showered. But above all, she made sure that I and my baby were fine: took our temperatures, checked my uterus, and weighted and bathed the baby. She made sure that breastfeeding was going well. She also run errands for me. While there are many problems with maternity care in the Netherlands, this is where the Dutch really get it right. After 8 days I was on my own again, but felt that her support helped me adjust to the new reality with two children.

Between the time I had my second and my third child, many things changed. For example, with this last pregnancy, I was no longer offered urine tests as they would only do them when elevated blood pressure was present. This time I had my eyes set on a birth clinic that was located in another hospital.

I still had the blood tests and ultrasounds (the midwives do the ultrasounds but for the 20 weeks scan you have to go to a special ultrasound clinic). When I found out that the baby is a boy I was scared that he’ll be big. The midwife told me that I can have a baby of about 4 kilo. This did nothing to alleviate my fears I and wanted to discuss the possibility of an elective C section but they wouldn’t have any of it. The midwife told me there is no medical indication for the operation.

Frustrated by the lack of support, I contacted a doula. We wrote a birth plan and talked about my expectations for this birth. In the end I realized that I didn’t want a certain type of birth, I just wanted my baby to be healthy, and to be healthy myself. On my birth plan, I indicated that I may want to get pain relief but when I called the birth centre to ask what they would do if I wanted pain relief, I was warned than then the birth would become medicalized and I’d have to go to the hospital and they made it sound like that was the worst thing that could happen to me.

My contractions started 9 days before his due date. The day before, my doula gave me a massage and I think that it helped start labour. This time we had friends to take care of the girls while we were in the hospital.

I called everybody: my husband, the midwife and my doula. My husband and midwife arrived almost at the same time and then my water broke. Again, it was thick with meconium. Again, I got transferred to the hospital. I informed my doula of the change of plans and we met at the hospital where again, my midwife told me she had to attend another birth and left me. Luckily, the team I got this time was amazing: this time I had a very friendly OBGYN and equally friendly nurses.

This time, I didn’t want to breathe through contractions: I just wanted to be comfortable. Since I was already in the hospital, I asked for a pethidine shot (I was progressing very quickly and an epidural was out of the question). I got it without any problems. The pethidine took the edge off the contractions, allowing me to relax more. My son was born shortly after that. He swallowed some meconium and was blueish at the beginning but soon pinked up. We went home the same day (although we stayed for dinner at the hospital) and again had an amazing kraamzorg.

I am very lucky that my babies were born alive and healthy. The care I got here was much better than I would have had in my home country, Poland. But it leaves a lot to be desired: for example women’s wishes for pain relief may easily be overridden by her midwife because she can’t administer it (midwives now can give sterile water injections and gas and air, and second line midwives can administer the pethidine shot, but for an epidural, an OBGYN and an anesthesiologist are required). I had to fight a lot for my needs to be met and I wish I didn’t have to.

It’s nice to have a midwife care for you during pregnancy, but if something’s wrong, you need to get transferred to a hospital. This means that the moment you are scared and at your most vulnerable, you have to change care providers, which only adds to your stress.

The system seems to work really well for women who have no problems during pregnancies and expect to have a natural birth. It also works for high-risk women who are taken care of by specialists- for example after previous pregnancy loss. But I guess the most cases fall somewhere in the middle and I wish such women wouldn’t be so pressed to have a natural birth and instead, would be offered more choices.

It’s getting ever more difficult for homebirth and natural childbirth advocates to defend safety claims. It’s pretty obvious that hospital birth is safer than homebirth and it’s pretty obvious that unmedicated childbirth is not safer, healthier or better in any way that childbirth with pain relief and interventions.

To camouflage their retreated on the safety issue, homebirth and natural childbirth advocates have conjured a straw man.

[perfectpullquote align=”right” bordertop=”false” cite=”” link=”” color=”” class=”” size=””]There is an entire medical specialty based on the assumption that there is more to childbirth than a healthy baby; it’s called obstetric anesthesia.[/perfectpullquote]

Milli Hill has been leading the charge in the UK. She thinks that she has discovered a deep, important, essential truth about childbirth:

… [A] healthy baby is not ALL that matters.

This article might push your buttons so before we go on I want to ask you to stay calm, grab a cuppa and keep your wig on. I need to be very very clear, because I know from experience that talking about this issue can cause an outcry. So please listen carefully. The following sentence is crucial:

When a woman gives birth, a healthy baby is absolutely completely and utterly the most important thing.

Got that? OK – do not adjust your wig, there’s more…

It is not ALL that matters.

Two things – just to repeat: a healthy baby is the most important thing, AND it is not all that matters.

Duh! Who ever said otherwise.

I own a lot of obstetrics textbooks, and I’ve read thousands of obstetrics papers, and never once have I seen anyone claim that so long as a baby is healthy it is acceptable to treat women shabbily.

Indeed, there is an entire medical specialty based on the assumption that there is more to childbirth than a healthy baby; it’s called obstetric anesthesia. A woman’s experience of pain is critical and attending to her desire for pain relief is a basic requirement for ethical obstetric care.

Oh, wait. According to natural childbirth and homebirth advocates, a woman’s experience of pain IS irrelevant. And that leads to some surprising “reasoning” on the part of proponents of “natural” birth.

Women matter too. When we tell women that a healthy baby is all that matters we often silence them. We say, or at least we very strongly imply, that their feelings do not matter, and that even though the birth may have left them feeling hurt, shocked or even violated, they should not complain because their baby is healthy and this is the only important thing.

Yes, when we tell women, as Grantly Dick-Read did, and as Lamaze and other natural childbirth organizations still do, that their pain is “good” pain, or “pain with a purpose,” we very strongly imply that their pain doesn’t matter. When we tell women as midwifery charlatan Ina May Gaskin claims that the excruciating pain of childbirth isn’t pain at all, just “surges,” we very strongly imply that how they experience childbirth is irrelevant. When we tell them, like quack Debra Pascali-Bonaro does that excruciating pain of childbirth isn’t merely a figment of their imagination, but is actually orgasmic, we very strongly imply not only that their pain is of no concern, but that they are gullible idiots to boot.

It is difficult for me to imagine a practice that more effectively silences women on their experience of childbirth than the entire natural childbirth movement.

According to Hill:

Too often women who say they care about the details of their baby’s birth day are accused of wanting an ‘experience’, as if it is selfish to care about how their baby is born, how they feel or how they are treated. But, as the saying goes, ‘when a baby is born, so is a mother’. If a mother feels broken, dispirited, depressed or traumatised, how will this affect her baby? Is this healthy?

That’s right. Too often women who choose pain relief in labor are made to feel as if they have failed. Too often women are told that if their baby did not transit their vagina, they haven’t really given birth. Too often women who choose C-sections to avoid the potential for vaginal tearing, future sexual difficulties or future incontinence are labeled “too posh to push.”

But Hill and her compatriots could care less about that.

Birth matters. To be respected, to be treated with dignity, to be in control of what happens to our bodies. To really feel the power of bringing a new life into the world – no matter whether in theatre or at home in a birth pool – why is it so wrong for women to want this?

It’s not wrong to want any of it, and no one, least of all obstetricians, ever said it was. What’s wrong is being willing to compromise safety to achieve it. What’s wrong is asserting without any evidence whatsoever that interventions and pain relief in labor hurt women and babies in an effort to chivvy women into opting for natural childbirth. What’s wrong is an entire group of medical professionals, midwives, promoting one form of birth, “normal birth,” above others.

How, pray tell, does discouraging epidurals promote women’s control over what happens to their bodies? How is a midwife delaying calling the anesthesiologist compatible with treating women with dignity? How does the relentless emphasis on unmedicated vaginal birth help women “to really feel the power of bringing a new life into the world – no matter whether in theatre or at home in a birth pool’? It doesn’t, of course.

Hill fails to see the irony when she insists:

What we do know is that many women DO care about what happens to them when they have their baby, but that they find it hard to talk about these feelings in a culture which persistently tells them that they really shouldn’t, and that what goes on in the delivery room is always acceptable as long as everyone survives.

The reality is that women DO care about what happens to them when they have a baby, but they find it hard to talk about these feeling in a natural childbirth culture which persistently tells them that what goes on in the delivery room is always acceptable as long as women refuse interventions, reject pain relief, and push their baby out their vagina.

Hill concludes:

A healthy baby is the most important thing, and it is not all that matters.

Respect, consent, choice, dignity – all that matters too.

If Hill and her compatriots really believe that they’d demand an end to promoting “normal birth.” They’d insist that a timely epidural is the right of every woman in labor. They’d favor giving every woman the option of a Cesarean by choice. And, as an added bonus, they’d stop the relentless campaigns to promote breastfeeding whether it is the right choice for the mother or not.

But that’s not what Hill and other natural childbirth advocates believe. They want respect for THEIR choices, not the choices of women who choose differently.

A healthy baby is not all that matters. Obstetricians have always recognized this. It’s time for natural childbirth and homebirth advocates to recognize that women’s experience of pain in childbirth matters. It’s time for them to recognize that sexual function after childbirth matters. It’s time for them to recognize that preventing incontinence matters.

It’s time for natural childbirth advocates to stop promoting “normal birth” and start promoting whatever women choose, whether they approve those choices or not.

Imagine that you’ve taken a job babysitting 7 year old twins. Each time you’ve babysat, they have been more difficult to supervise. They run riot through the house breaking things and then begging you to fix them before their parents get home. The final straw, though, was when you went to check on them playing quietly in their room and found that they set the bedding on fire with matches they retrieved from their night stand. After you put the fire out (the bedding is a total loss), the twins insist that they are allowed to play with matches.

You confront the parents when they get home; they acknowledge that yes, they did not have the heart to take the matches away from the twins because they really love fire. You announce that you are quitting the job and the parents confide that you are the 4th babysitter to quit in the last few months.

How would you feel if several days later you saw the parents alone at a movie theater and they cheerfully informed you that they left the twins home by themselves, because they begged to be left alone and promised to be good?

That’s exactly how many obstetricians feel when they learn of legislative attempts to dispense with physician supervision of midwives.

The latest effort is taking place in North Carolina:

North Carolina law has required for more than 30 years that certified nurse midwives — the only kind allowed to practice in the state — operate under the supervision of a licensed, practicing obstetrician.

The new law would require that midwives, “consult collaborate with or refer to other providers” if indicated by the health status of the patient. Certified nurse midwives would continue to be allowed to write prescriptions, now without the supervision of a doctor.

“This is huge for us,” said Jan Verhaeghe, a certified nurse-midwife with New Dawn Midwifery in Asheville. “To be considered independent providers, working as colleagues rather than one party having total liability. We may see many more nurse midwives moving to the area without these types of restrictions.

The impetus for the legislation is refusal of obstetricians to back up certified nurse midwives (CNMs) who attend homebirths. Although the newspaper article references a homebirth disaster attended by an uncredentialed “midwife,” the proximate cause is disasters at the hands of CNMs attending homebirths.

The problem erupted in May [2012] when Henry Dorn, MD, a High Point-based obstetrician, informed seven midwives he supervised that he could no longer serve as their licensed physician. Around the same time, another doctor supervising an eighth midwife told her that he could no longer afford the insurance costs.

Dorn’s action came in the wake of a homebirth death at the hands of one of the CNMs he was ostensibly supervising.

Since then CNMs who want to attend homebirths have found it exceedingly difficult to obtain obstetrician supervision. That’s entirely appropriate! No one wants to supervise anyone who is a danger to babies.

The situation is startlingly analogous to the twins who play with matches. The number of deaths at homebirth in North Carolina is astronomical, but the state is like the parents who won’t remove the matches. The only fail-safe has been the requirement for physician supervision, since midwives on their own refuse to recognize the danger.

The midwives insists that they will now bear responsibility for their own outcomes:

Advocates say the law eliminates undue restrictions on qualified practitioners, and “inappropriate liability” for physicians.

That’s as reassuring as the 7 year old twins who promise they will be careful with matches.

In case, the legislators in North Carolina have trouble imagining what happens when unsupervised midwives are responsible for a homebirth death, they can look to Michigan for reference.

Three years after their baby died following a botched breech delivery at an Okemos birthing center, a DeWitt couple has been awarded $5 million in a lawsuit against the midwife in charge of their son’s birth.

Ingham County Circuit Judge Clinton Canady has ordered former nurse midwife Clarice Winkler to pay Sara and Jarad Snyder damages for the death of their son, Magnus, in 2011.

However, it’s unlikely the Snyders will collect any money because Winkler did not carry malpractice insurance, said the couple’s attorney, Brian McKeen.

What happened to Magnus?

Sara went into labor on April 8, 2011. After nearly six hours of pushing, Magnus was born up to the chest, but his head was stuck.

For seven minutes, according to the lawsuit, Winkler attempted to pull Magnus from Sara’s body. He was eventually freed but was born blue and lifeless.

Greenhouse called paramedics four minutes later when their efforts to revive him failed.

Magnus spent 13 days in Sparrow Hospital’s neonatal intensive care unit before passing away from severe brain damage and organ failure.

The only time he opened his eyes, Sara said, was the moment before he died.

How did the midwives who presided over Magnus’ birth take responsibility for his death?

The Snyders originally sued Greenhouse Birth Center and three of the Greenhouse midwives who were present during Magnus’ birth — Winkler, nurse midwife Shelie Ross and a third midwife, Audra Post, who holds a non-nurse credential called certified professional midwife.

The midwives all filed for bankruptcy after the suit was filed.

In attempt to obtain some accountability, the Snyders filed a lawsuit against Winkler, the lead midwife. How did she respond?

She didn’t even bother to show up.

A baby died, and every single midwife involved washed her hands of the situation. Their concern extended only as far as protecting themselves and evading responsibility.

The conclusion is inescapable:

When midwives are so irresponsible and reckless with babies lives that obstetricians refuse to supervise them, only fools could imagine that the solution is to dispense with supervision. This is not a theoretical issue. The obstetricians’ refusal to supervise midwives is a direct consequence of babies who have died preventable deaths.

If this were healthcare, midwives would be drafting new and more stringent requirements both for supervision and to restrict homebirths.

But this is politics, so instead they are lobbying to free themselves of the last restriction on their irresponsible behavior.

The politicians are imagining the votes they might garner. The midwives are imagining the freedom from scrutiny they might obtain.

And no one but the obstetricians gives a damn about the babies who will die as a result.

Whenever homebirth advocates get around to acknowledging the increased death rate at homebirth, they invariably characterize it as “tiny.” They typically say things like: The risk of neonatal death in the hospital is tiny, so even if they homebirth death rate is several multiples higher, several times tiny is still tiny.

To put that “tiny” death rate in perspective, it might be useful to do a thought experiment: what if formula killed as many babies as homebirth?

I’ve chosen to use formula as an example, because homebirth advocates are almost always lactivists as well, fanatically in favor of breastfeeding and remarkably intolerant of women who choose to bottle feed. Indeed, they have pushed governments of first world countries like the US to spend millions of dollars on public health campaigns to convince women to breastfeed when there are only soft benefits (fewer colds) and most of those soft benefits aren’t even proven.

Can you imagine the field day they would have if they could actually point to deaths directly attributable to formula?

Let’s suppose that formula feeding had an excess death rate over breastfeeding similar to Oregon’s excess death rate at homebirth. I’ve chosen Oregon’s data because they are the most comprehensive statistics currently available. In Oregon, hospital birth for low risk women has a neonatal death rate of 0.6/1000 (“tiny”) and a neonatal death rate at homebirth with a licensed midwife of 5.6/1000 (9X “tiny”) for an excess death rate of 5/1000.

There are 4 million babies born in the US each year. It’s not a stretch to assume that 3 million receive formula at some point during their first year. A death rate of 5/1000 translates to 15,000/3,000,000. Spread over a year, that rate would lead to the death of 41 babies who died unexpectedly each and every day simply because their mothers chose bottle feeding over breastfeeding.

Homebirth advocates/lactivists would go nuts. They would push for even greater government spending on breastfeeding promotion and support. They would decry women who found bottle feeding more convenient and in better keeping with working outside the home. They would undoubtedly taunt mothers for literally risking their babies’ lives for no better reason than the mothers’ “experience.”

It would not end there, though. The FDA would be investigating formula manufacturers, pulling products from the market and funding research to make safer formula. There would be extensive evaluation to determine if some formulas were safer than others. If it were found that the excess death rate was due to improper manufacture or testing of formula, fines would be levied and formula executives might even go to jail. Factories that had the highest death rates would almost certainly be closed. Parents would be suing those formula manufacturers and they would be winning large judgments. In short, a “tiny” excess death rate would trigger a massive reaction, because such a death rate would be viewed as appalling and utterly unacceptable.

So here’s my question to homebirth advocates:

What would you think of mothers who chose formula feeding over breastfeeding, knowing that 41 babies would unexpectedly die each and every day for no other reason than their mothers’ refusal to breastfeed?

More importantly:

Why shouldn’t women who choose hospital birth think the same thing about you?

Aviva Romm is a quack.

She’s a certified professional midwife (CPM) and an herbalist, both quacks by definition. She got an MD (from Yale!!!) and completed a family practice residency, which apparently taught her a few things. No, it didn’t teach her to give up quackery. It merely taught her to avoid any situation where should could be held accountable for her quackery. Delivering babies was awesome when she planned to take no responsibility. Now that she has an MD, and carries malpractice insurance, it is suddenly too dangerous to do or to even back up.

Dr. Romm has helpfully provided us with an excellent example of the standard quack attack in her most recent post, Gestational Diabetes: Please Don’t Drink the Glucola Without Reading the Label.

All quack attacks rest on two foundational claims:

1. Don’t trust the people who are trained in the specific area under discussion, the people who went to school, undertook an internship and residency in obstetrics, and have provided obstetric care to thousands of women, and stand ready to accept responsibility for the advice that they offer; trust me (who did not do a residency in obstetrics, and chooses not to practice obstetrics, and intends to take no responsibility for her obstetric advice) instead.

2. Obstetricians aren’t simply ignorant, they are actively conspiring to harm your baby with chemicals … AND THEY ARE HIDING THEIR EVIL INTENT.

Sounds stupid, right, but Romm, like all quacks, bets on the stupidity and gullibility of her readers.

In addition, quacks are always selling something, in Romm’s case, her books, her courses, and her services separating the worried well from their money at a high end clinic that caters to the rich and charges exorbitant prices.

Consider the specific claims in Romm’s quack attack on Glucola, the test dose of sugar used in screening pregnant women for gestational diabetes.

I’m a midwife and MD who specializes in the health and wellness of pregnant mommas. While I’m one of the original crunchy mamas, I got the science thing down tight in my medical training at Yale, so I can keep you informed on what’s safe, what’s not, and what are the best alternatives.

Bullshit. She isn’t an obstetrician or an endocrinologist so she DOES NOT specialize in the health of pregnant women. She has no business giving obstetric or endocrinology advice. She went to medical school at Yale. Woop-de-doo! Did they teach anything about Glucola in medical school? I doubt it.

The medical community considers this “drink” harmless though it is well recognized that some women just can’t tolerate it due to digestive system side effects including nausea, vomiting, bloating, and diarrhea, as well as other adverse reactions including headache, dizziness, and fatigue.

But Romm thinks she knows better, despite lacking the requisite training. And Romm thinks she knows that … cue the creepy music … obstetricians are secretly trying to poison your baby!!

… [A]t least one of the glucose test drinks EasyDex, by Aero Med (note that ingredient lists from the test companies are notoriously hard to find online!) contains something called BVO, or brominated vegetable oil. BVO is also found in at least 10% of all soft drinks in the US, and is included to keep the favoring from floating to the top of the beverage.

According to the Center for Science in the Public Interest, “safety questions have been hanging over BVO since 1970, when the FDA removed BVO from its ‘Generally Recognized as Safe’ list of food ingredients.” At that time, the FDA granted BVO ‘interim status’ as a food additive which allowed its use in soft drinks, but it was and remains banned from European and Japanese soft drinks. BVO is patented in the U.S. and overseas as a flame retardant.

Classic quack attack characteristics: isolate one product and let it stand in for all products of that type, insinuate that the product is harmful, list the countries where it is banned (don’t say in what dose or why), imply that because it has other uses, it must be poisonous.

How about proof?

Don’t be foolish. Quacks don’t need any proof. Quacks quote lay people as if they were scientists and blogs as if they were scientific papers.

Vani Hari (aka The Food Babe), a food activist who is bringing fresh attention to the hazards of the chemical additives in our foods, brought the … issue to my attention when we were chatting at a conference. We both agreed that this toxin should not be given to pregnant women!

Romm uses another favored quack source, the product label. As she undoubtedly knows, doctors don’t read the product label to learn about a medication and you shouldn’t either. The product label has more to do with legal protection than with medical knowledge.

Can Aviva Romm point to anyone who has been harmed IN ANY WAY by Glucola? Of course not. Doctors who care for patients need actual data. Quacks just need insinuations.

All the central quack claims are here, rolled into one: don’t trust your doctor, your doctor is trying to poison your baby, read the product label (not the scientific literature), scary insinuations and no actual proof of ANYTHING.

Now that Aviva has filled the heads of her gullible minions with her conspiracy theory, she presses on with phase two of the quack attack: praise those who believe her bullshit as educated and empowered.

As women, many of us were taught to “be nice,” or “be seen and not heard.” As patients, this can translate into accepting tests, procedures, and treatments that we feel we don’t want or need, or that, in this case, might not be safe for us or our babies!

You certainly have the right to read the label on the glucose test drink you are offered before agreeing to the test!

You also have the right not to be screened for GDM, as well as to choose your preferred screening method…

Just what women need, encouragement to be arrogant in their ignorance.

But I have bad news for Romm’s minions, eager to believe that they are learning something that other women don’t know:

Aviva Romm is in the pocket of Big Placebo. Her income rests on tricking women into paying her for her useless (and often harmful) “wisdom,” instead of learning from the people who know the most about obstetrics. She is shilling for her products and her pocketbook.

And if you think she cares about what happens to your baby, I have a bridge for you to buy in Brooklyn.

Aviva Romm KNOWS that homebirth kills babies. That’s why she refused to discuss the MANA data; she KNOWS it shows that homebirth is dangerous. And that’s probably why she refuses to have anything to do with homebirth as a practicing physician. She no longer wants to be responsible for the death and injury that may result.

Romm should be ashamed of herself and her quackery, but she probably has no time; she’s busy making money from fooling unsuspecting women, and potentially harming their babies in the process.

People often ask me why I blog about the risks of homebirth and other birth choices. This email from a reader, along with her baby’s story, is one of the many reasons why.

The baby’s mother wrote:

This is the birth story of my sweet baby boy…

Thank you for steering women to make the right choices. Because of you I decided to attempt my VBAC in a hospital and for that I am very grateful.

Here is her story:

This story starts off with the reason I had my first cesarean. With our daughter I suffered a ruptured brain aneurysm. In order for me to receive the medication to prevent me from having a stroke the doctors decided to perform a cesarean section at 34 weeks. I was under general anesthesia and my brain was swelling so I do not remember meeting her until she was two weeks old.

Fast forward to just before I became pregnant with S, I had to be cleared not only by my obstetrician but also my neurosurgeon. All was clear and I was given the doctor’s blessing to try for another child.

With this current pregnancy I sought to have a vaginal birth after cesarean (VBAC) because of the horrible experience I had with my daughter. I wanted to experience labor and be present for his birth. I narrowed it down to a hospital that performed VBAC and I had all of my prenatal care there.

I was considered the perfect candidate.

1. I had waited 22 months in between pregnancies.
2. I had double suturing on my old incision
3. My cesarean was not due to a labor problem (stalling, not descending, etc)
4. I was young, 25
5. I was healthy, thin and active.

My pregnancy was uneventful. At my 40 week appointment I had the doctor strip my membranes and it sent me into labor. Overnight I kept cramping so I decided to go to the hospital. (I was told to go in early and I did). When I got there my contractions stopped. I thought to myself “Let’s just have this baby!”

I was checked and was dilated 2 cm, and then an hour later I was 3. They decided to admit me because I was attempting a VBAC. When I got to my room, I asked that the doctor break my water and after that I got the epidural. (I had pitocin at a level 4, then a 2 and the doctor decided to turn it off because I was progressing beautifully. I don’t know if this affected my rupture or not). An hour later I was checked at a 5, and an hour after that I was complete. A lot of people rushed into my room to prepare for delivery.

The doctors told me to push but I couldn’t. I was in such pain in my upper abdomen but no one seemed to notice. The anesthesiologist told me that not all epidurals get rid of the pain.
Meanwhile my baby was having rapid heart decels. They tried turning me on my side and placing an internal monitor. Immediately after placing the internal monitor, the attending physician checked me (residents did deliveries) and called a cesarean. I was also experiencing reverse dilation. My babies heart rate was in the 30s.

They wheeled my immediately into the operating room. The doctor started to cut me open before the sheet was even up and I was not anesthetized properly. Decision to incision was less than 5 minutes. All I remember was the doctor saying “uterine rupture”. My old incision opened up and my baby was in my abdomen.

I screamed as they pulled my baby out, it was very painful. My baby was not crying.

Baby S was born at 8lbs 7.7oz and 22 inches long.

By then the anesthesiologist gave me so much medicine that I couldn’t move or talk. I just lay there. I was in surgery for over an hour and a half, and the doctors were working to save my uterus. I had suffered a placental abruption as well as the uterine rupture. The doctors believe that because my uterus ruptured I had the placental abruption.

My baby was not breathing. Because he needed a complicated procedure that the hospital was not prepared for they took him to Texas Children’s Hospital.

I was in recovery experiencing shock from blood loss and I got transfusions. I was shaking for hours after the surgery. The worst was yet to come, and I had to go to postpartum alone while I heard other babies crying and I did not have mine. My husband was at Texas Children’s Hospital.

In the middle of the night the doctors at Texas Children’s called me for permission to do a blood transfusion for S. I agreed and just wanted to see my son. At the time I did not fully understand what was wrong with him. The hospital released me after just 2 days so I could go see him.

When I got to the S’s hospital the doctors there were asking for consent to perform surgery. They already had him “cooling” on a pad that dropped his temperature very low. My baby felt dead. He was not conscious. The surgery was for an ECMO machine, a last resort machine that is used for life support. They told me our son would die without it so we agreed.

He ended up on life support for 10 days until they felt he would survive on his own. Another week passed and we finally heard his first cry. We stayed at the Ronald McDonald house for most of the time but we also had another child to take care of so we didn’t get to see him every day. That was very hard on our family and week later he came home with us.

While at the hospital he had an MRI done and told us that he had brain damage but they don’t know how extensive it will be until he gets older. That is the hardest part, not knowing. Right now he is a healthy growing boy and we love him. He seems to not have any effects from his birth and is meeting his milestones on time.

I’m writing this to let all women know of the risks of VBAC, because uterine rupture does happen. It’s not talked about very much and it should. Women should be totally aware of the risks before they attempt a VBAC. Please attempt your VBAC in a hospital equipped to do immediate surgery like mine was. While I was aware of the risks, I didn’t think it could happen to me. I was wrong.

I’m so thankful to both hospitals and the doctors that provided me with such great care. I’m just lucky my baby survived.

On Mother’s Day I wrote about my firm belief that love makes a mother, not birth choices.

But apparently, loving your child is no longer enough. Contemporary natural parenting aficionados appear to view their children as status symbols whose birth and feeding serve to proclaim the superiority of their mothers. Just as in certain circles artisanal food proclaims a superior hostess, in parenting circles specific parenting practices, natural childbirth, breastfeeding, family bed, etc. proclaim a superior mother. I think of these parenting practices as artisanal mothering.

What does artisanal mean? According to Dictionary.com:

pertaining to or noting a high-quality or distinctive product made in small quantities, usually by hand or using traditional methods

Traditional, and traditionally labor intensive processes are required to produce artisanal cheese or artisanal bread. The maker takes no shortcuts, and avoid all conveniences in producing artisanal products, and that supposedly makes for a superior product. Greater suffering = higher quality.

In the world of natural parenting, traditional and traditionally painful and inconvenient processes are required to produce artisanal children. The mother takes no shortcuts, and avoids all conveniences and that supposedly makes for superior children. Greater suffering = higher quality.

Personally, I blame Martha Stewart for the obsession with artisanal products. Don’t get me wrong; I love Martha. The foyer of my home is graced by a vase, stenciled over faux painted walls, above a hand made, decoratively shaped shelf. Martha showed me how to do it, told me I was capable, and sent me off to buy stencils, faux painting supplies and a jig saw. I’m proud of how it all came out and how many thousands of dollars I saved in the process. I suffered to produce the vase, painted walls and handmade shelf, but I don’t kid myself; it’s only cheaper than what a professional could have produced, not better. Professionals probably could have done a superior job.

Similarly, artisanal children may be cheaper to raise, and require a great deal more suffering on the part of the mother, but they are not a superior product. Natural childbirth can produce an agonized mother and a cheaper delivery, but not a better baby. Indeed there is considerable evidence that traditional methods of giving birth are more likely to produce a damaged child than hiring a professional. Breastfeeding may take an extraordinary effort and commitment on the part of the mother, and may be cheaper to provide, but it doesn’t make for a better baby. Indeed, in some settings, formula is actually better for babies. The family bed may more inconvenient for the parents and cheaper than a separate crib, but it does not provide a superior baby, either. In the world of mothering, there is no evidence of any kind that traditional methods involving a lot of physical suffering on the part of the mother produce a superior product.

Artisanal mothering (natural childbirth, breastfeeding, baby wearing, co-sleeping) emphasizes process over outcome. But in raising children, it is outcome (happy, healthy children) that matters, not process. Moreover, children should be viewed as ends in themselves, not as means for demonstrating maternal superiority.

Buying in to natural parenting is like buying artisanal cheese. If you like it, and it works for you, go for it! But don’t ever confuse what you like with what is best. Buying artisanal cheese does not mark you as a socially superior person, and buying into natural parenting does not mark you as a better mother.

A new study recently published in the Journal of Human Lactation, is making the rounds in lactivist circles. However, the study, in addition to being underpowered to reach any conclusions, treats lactating women as if they are nothing more than cows, reducing them to the characteristics of the milk they produce, without any regard to their pain, needs and desires.

The study is Relationship between Use of Labor Pain Medications and Delayed Onset of Lactation by Li et al. and the findings are:

Overall, 23.4% of women in our sample experienced DOL. Compared with women who delivered vaginally and received no labor pain medication, women who received labor pain medications had a higher odds of experiencing DOL: vaginal with spinal/epidural only (aOR 2.05; 95% CI, 1.43-2.95), vaginal with spinal/epidural plus another medication (aOR 1.79; 95% CI, 1.16-2.76), vaginal with other labor pain medications only ([not spinal/epidural]; aOR 1.84; 95% CI, 1.14-2.98), planned cesarean section with spinal/epidural only (aOR 2.13; 95% CI, 1.39-3.27), planned cesarean with spinal/epidural plus another medication (aOR 2.67; 95% CI, 1.35-5.29), emergency cesarean with spinal/epidural only (aOR 2.17; 95% CI, 1.34- 3.51), and emergency cesarean with spinal/epidural plus another medication (aOR 3.03; 95% CI, 1.77-5.18).

The authors concluded:

… [M]others who received pain medications during labor and delivery were more likely to report that they experienced DOL. Because 83% of mothers in the U.S. use pain medication during labor and delivery, the implications of a link found between labor pain medications and onset of lactation, if causal, is of public health and clinical impor- tance.

How did the authors assess delayed onset of lactation? They used a notoriously unreliable method, a questionnaire, which asked mothers to recall the answer to a remarkably vague question:

“How long did it take for your milk to come in?” (1 day or less, 2 days, 3 days, 4 days, more than 4 days).

That’s only one of the six serious limitations to the study acknowledged by the authors:

This study is subject to at least 6 limitations. First … the study sample is not representative of the US population … which prevents generalization of our findings to the entire US population. Second, IFPS II [the questionnaire] did not collect information regarding dose of labor pain medication used ..; therefore a dose-response relationship between pain medication dosage and risk for DOL could not be examined. Third, while overall this was a large study, there were relatively small percentages of mothers exposed to some of the pain medications, which … limited our ability to evaluate the effects of specific medications. Fourth, because we are unable to separate cesareans from labor pain medication use, we are unable to evaluate the effects of the medications used independent of method of delivery. Similarly, we are unable to separate the pain associated with labor/delivery from the use of labor pain medications; therefore, we are unable to tease out whether it is the pain or the pain medications leading to the associations that we observed with DOL. Fifth, data regarding labor course were not collected in IFPS II; therefore we were unable to adjust for labor characteristics such as length of labor, length of second stage labor, or labor/delivery stress, all of which are known to be associated with DOL. Finally, all data were self-reported; hence outcome and exposure misclassification are potential limitations of the study.

So the design of the study itself renders the conclusions virtually useless, and that’s even before we get to the fact that the study is so underpowered that the conclusions are statistically useless.

The number of women in the study as a whole was small, and the number of women in each subgroup was tiny, rendering any conclusions highly suspect from a statistical point of view.

The bottom line, therefore, is that the conclusions of the study are meaningless.

Let’s leave aside for the moment the fact that the authors failed to adequately support their conclusions, and failed to demonstrate that the parameter they are measuring was even remotely clinically relevant (since they never looked at the health of the babies). The study does shed some light on another important issue: the tendency of lactivists to treat women like cows, obsessing about the quality and quantity of their milk, with no regard to the well being of the women themselves. I cannot think of any other study in the literature that rests on the presumption that treating excruciating pain is optional and possibly undesirable, but that is the foundational assumption of this paper. The implicit message of the authors is that women should forgo pain medication in order to “optimize” their breastmilk.

This is especially ironic in light of the confluence between natural childbirth advocacy and lactivism. Evidently the mother’s “birth experience” and desire to avoid lifesaving interventions and C-sections is supposed to take primacy over the baby’s interest in being born alive and neurologically intact. But the situation is magically reversed when it comes to breastfeeding. The mother’s experience is completely irrelevant and all that matters is optimizing the breastmilk that the baby receives.

How, in good conscience, can any group of investigators completely dismiss the mother’s pain in labor? How can they, in good conscience, presume to sway women against pain relief in labor in favor of a highly theoretical benefit that they are incapable of demonstrating even exists? It’s apparently very easy. In the world of lactivism, the wellbeing of the milk producer is irrelevant; only the consumer matters. Here’s what I’d like to know: how is that different from treating women like cows?

Our right to bodily autonomy is one of the most important rights that we have. Simply put, a woman (or a man) has a right to refuse medical or surgical treatment, regardless of whether or not the refusal might lead to death. In the case of a pregnant woman, that means that she has an absolute right to refuse a C-section regardless of whether the C-section is life saving for either her or her unborn baby.

If the facts of the case as outlined in The New York Times are correct, Rinat Dray has an excellent case against her doctors for performing a C-section without her consent.

After several hours of trying to deliver vaginally and arguing with the doctors, Mrs. Dray was wheeled to an operating room, where her baby was delivered surgically.

The hospital record leaves little question that the operation was conducted against her will: “I have decided to override her refusal to have a C-section,” a handwritten note signed by Dr. James J. Ducey, the director of maternal and fetal medicine, says, adding that her doctor [[Dr. Leonid Gorelik] and the hospital’s lawyer had agreed.

They should not have done that, and, given the facts that we know so far, it is difficult to imagine why the hospital’s lawyer gave them the go-ahead to do so.

Ms. Dray had had two previous C-sections:

… [T]he first doctor, at NewYork-Presbyterian/Weill Cornell hospital, began urging her to have a cesarean after her water had broken and she had labored for a few hours. Hoping for a different outcome for her second pregnancy, she went to Lenox Hill Hospital, with the same result.

Still hoping for a vaginal birth, she changed doctors again for the third pregnancy. She also hired a doula to help her with the childbirth.

In other words, Dr. Gorelik agreed to take her on as a candidate for a VBA2C. This was clearly a priority for her, and Gorelik knew it and assented to it. Presumably he had extensive discussions with her during the pregnancy about the risks and benefits of a VBAC attempt. Yet after, Ms. Dray labored for several hours, Dr. Gorelik changed his mind.

At first, she said, Dr. Gorelik appeared to relent, saying he would give her an epidural for the pain and then reconsider. “I was begging, give me another hour, give me another two hours,” Mrs. Dray said. Her mother, who was there, supported her, and the doctor said, “I’m not bargaining here,” Mrs. Dray said.

Mrs. Dray said she kept begging on the operating table. His answer, she recalled, was, “Don’t speak.”

Those exchanges, if true, are shameful. It appears that the doctor substituted his judgment for Ms. Dray’s and performed surgery against her will.

There are, of course, situations in which a doctor can perform surgery without explicit consent, but it doesn’t sound like this was one of those situations. In emergencies if a patient is incapable of giving consent for life saving treatment (e.g. if the patient is unconscious after being shot), consent for life saving treatment is assumed since the patient would consent if she or he were aware.

Yet, Ms. Dray’s situation does not sound like an emergency. No one was suggesting that her uterus had ruptured, for example, or that the baby was currently dying. Moreover, Ms. Dray hadn’t been unable to give consent; she deliberately withheld it.

An emergency C-section without explicit consent might be performed if the doctor feels that the patient is incapable of understand what is going on. There’s no evidence presented thus far that Ms. Dray did not understand exactly what was happening. Indeed, there is no evidence that any of the factors that might imply consent were occurring here. The doctor wanted to perform a C-section, the patient refused and the doctor did it anyway. That is inappropriate and inexcusable.

Dr. Howard Minkoff, chairman of obstetrics at Maimonides Medical Center in Brooklyn, whose articles on the subject of patient autonomy have been published in medical journals, said he believed that women had an absolute right to refuse treatment even if it meant the death of an unborn child. “In my worldview, the right to refuse is uncircumscribed,” Dr. Minkoff said, cautioning that he was not commenting on the particular facts of Mrs. Dray’s case. “I don’t have a right to put a knife in your belly ever.”

I heartily concur, and I suspect that the court will, too.

We are not talking about someone who is unknown to the doctor, who is in the midst of a dire emergency, who is incapable of understanding what is going on. We are talking about a competent woman who had had extensive counseling by her doctor, who strongly wished to proceed with labor, who strongly expressed that she did not give consent, and yet was operated on anyway.

Ms. Dray has the RIGHT to refuse consent for a C-section. She has the RIGHT to let her baby die if that’s what happens as a result of refusing a C-section. She has the RIGHT to sacrifice her own life, too, if she understands that she might die as a result of her refusal.

Ms. Dray’s doctors apparently trod on all those rights and substituted their judgement for hers. If that is truly the case, they can and SHOULD be held legally accountable.

For me, one of the most distressing aspects of homebirth is thinking about the experience of the babies.

Their very lives are on the line for no better reason than because their parents are seeking a specific experience. While their mothers wallow in their birth pools, and while their fathers wallow in their empowerment, the babies may be suffocating to death, struggling to extract enough oxygen across a failing placenta to feed their fragile brain cells, or gasping with heads stuck in the vagina while their bodies dangle outside because their mother attempted a breech birth at home, or drowning in a sea of bright red blood, the oxygen so close yet utterly inaccessible because their mother’s uterus has rupture during an attempted VBAC at home, extruding them into the abdomen with no way out and no way to survive.

When the survivors grow to adulthood, might they treat their elderly parents the way they were treated, as a prop in their parents stories. Might they put the lives of those elderly parents on the line to return the favor of valuing experience over their well being?

That thought came to mind reading the narcissistic drivel from M. Landers, a father whose third child was recently born in a home VBAC. Landers mused on great existential questions, like pain and death, in The Tragedy Of Childbirth: If It Hurts, Embrace It

I envision his son eventually writing a piece entitled The Tragedy of Old Age: If It Hurts, Embrace It.

The heart of Landers’ piece is his attempt to explain why he and his wife are cavalierly risking the life and health of a postdates baby in a homebirth. It purports to be deep, but is really nothing more self-indulgent, puerile rationalization:

… People can argue statistics day and night about the safety and ethics of homebirth v. hospital birth or vaginal v. C-section, but in the end I think our prefered [sic] stance really comes out of our capability to accept life-threatening and potentially tragic situations without attempting to control them. No one wants to stand by and watch tragedy befall their loved ones, but it is a constant and real possibilty [sic]. While we understand a lot about the human body and how to “successfully” modify its efforts at the birthing process, the truth is that it knows what it’s up to and often our attempts to improve upon its effects can just as easily thwart an ideal outcome.

Imagine Mr. Landers at age 80, hobbled by arthritis, nearly blind from cataracts and suffering chronic pain from who knows what. He doesn’t know, because his son, who is now his caregiver, refuses to take him to a doctor anymore, because all that doctor did was implore the son to buy expensive prescription medicines to ease his father’s arthritis, pay for expensive surgery to remove his cataracts, and subject his father to expensive tests for no better reason than to figure out cause of his chronic pain. The doctor has gone so far as to play the “dead father card,” warning that his father might die without expert care.

How would Mr. Landers feel then if his son exhorted him thus?

Dad, this is old age. If it hurts, embrace it.

If Landers wept for access to cataract surgery, desperate to be able to see, read and write again, would he be satisfied with this?

My preferred stance on this issue really comes out of my capability to accept life-threatening and potentially tragic situations without attempting to control them. I’m sorry that you’re nearly blind, Dad, but you ought to trust vision more and not attempt to control it.

And if Landers begged for access to medical care, expressing his fear that he might die as a result of whatever was causing his chronic, debilitating pain, would he be mollified by this?

Dad, no one wants to stand by and watch tragedy befall their loved ones, but it is a constant and real possibility. While we understand a lot about the human body and how to “successfully” modify its efforts at the aging process, the truth is that it knows what it’s up to and often our attempts to improve upon its effects can just as easily thwart an ideal outcome.

It sounds unspeakably harsh and cruel, doesn’t it? Yet how different is that from Landers’s own philosophy on risking the death of his son at homebirth?

Not very.

We understand how heartless and selfish the son is because we can easily envision ourselves in the position of an elderly Landers. We can imagine the grief at his loss of sight, his chronic pain and his fear of death. In contrast, it is difficult to appreciate the position of a homebirth baby, since we know that we will never again face the risk of injury and death at our own birth. But just because it is easier to put ourselves in the place of an adult instead of a baby, does not mean that the baby is suffering any less.

We quail at the thought of being treated like the elderly Landers; we ought to quail at the thought of being treated like Landers treated his son.

Landers better hope that his son give more thought to his comfort, safety, and very life, than Landers gave to him.