Have you ever noticed that there are certain statements that automatically mean the opposite of what the speaker intends?

The classic example is “I’m not racist but …” You just know that whatever follows those words is going to be racist.

According to Rational Wiki:

Any sentence that starts with the words “I’m not prejudiced, but…,” or similar formations (“I’m not racist, but…” or “I’m not homophobic,” “not sexist,” etc.) is likely to contradict itself very rapidly… Saying a sentence that starts with “I’m not X, but…” likely means that you are X.

The exact same principle applies to the favorite phrase of natural parenting advocates. That phrase is “I’m educated and …”

Popular formulations include:

I’ve educated myself about natural childbirth or homebirth or vaccination and …

I’ve done my research on natural childbirth or homebirth or vaccination and …

It is virtually guaranteed that whatever follows is going to be absolute nonsense.

Why?

When a natural parenting advocate claims to be “educated” about medical topics, she certainly doesn’t mean that she went to medical school, has hands on training caring for pregnant women and babies, or is familiar with the obstetric, neonatology or immunology literature. What does she mean? She means that she has adopted a cultural construction of “education” that has little if anything to do with actual knowledge of the topic. She means that she has used Google to access information that may or may not be true. She has ignored those who have actual education and training and crowd sourced her decisions by reading books, blogs, websites and message boards written by other lay people who are often equally ignorant.

A lay person’s claims to be “educated” about a health topic is really a claim of defiance. The person is proudly defying the recommendations of health experts with years of education and years of training in order to credulously accept the bizarre conspiracy theories and absolute nonsense of people who have little or no education and training in the relevant discipline. When a homebirth advocate or vaccine rejectionist claims to be “educated,” she means that she has thoroughly read and blindly accepted the propaganda of other people who are equally uneducated.

What’s doubly ironic about the claim of being “educated” is that people who really are educated on a topic never proclaim themselves to be “educated.” They might tell you about their training, their years of schooling, their professional titles or the papers they have published on the topic, but they will rarely if ever claim to be “educated.”

When someone tells me he is not racist but …, he has helpfully alerted me that the statement that follows is likely to be racist.

And hen someone tells me she is “educated” about childbirth, homebirth or vaccination, she has helpfully alerted me that she is thoroughly ignorant about that topic and about what being educated really means.

On Friday I wrote about Jennifer Margulis’ pride in being singled out as one of the birth blogger buffoons.

Margulis wrote on her Facebook page:

A midwife who just requested my friendship on Facebook pointed out that I made the hit list of a notorious internet troll yet again! I am in good company with Ricki Lake and Jen Vbacfacts Kamel…

In response, I publicly offered to debate Margulis:

… I’ll debate you in print on natural childbirth, homebirth, vaccines, whatever you prefer. We can publish the debate on both your blog and mine so there will be no chance of altering our words. Then everyone can vote in the comments sections about who was more persuasive.

I’ll be waiting for your response, but I’m not holding my breath because I could turn awfully blue (just like those hypoxic homebirth babies). You’ll never agree and like Jennifer Block, Henci Goer, Ricki Lake, et al. you’ll run in the opposite direction as fast as you can.

You know as well as I do that you would be eviscerated and publicly humiliated in no time at all, so you won’t dare agree.

Margulis took 24 hours to think about it and respond thus:

Amy Tuteur I would be delighted to debate you on the topic of your choice. I’m astonished and delighted at your invitation, since you have dismissed me as a “clown” and a “joke” in your latest blog post! But no worries, if you’d like to spend time exchanging ideas with a “clown,” I’d be glad to. Let’s find a neutral public space to do a live televised debate. I am not interested in a popularity contest (you win for having the most vociferous and best organized blog commentators out there), but I am interested in shedding light on these issues and helping women and their partners make informed choices about their health and the health of their children. I look forward to a rational debate that will not include words like those in your invitation like “eviscerated” and “publicly humiliated,” or the ad hominem attacks on your blog. Is that something you would be interested in? Please PM me your phone number so we can work out the details.

Margulis appears confused as to why I would want to debate someone I have dismissed as a clown and a joke, so I will explain:

Jennifer Margulis, I want to debate you because I think you are DANGEROUS.

I hold you personally responsible for putting children and babies at risk by your support of quackery. I would not be surprised if you are personally responsible for serious childhood illnesses in those who follow your advice about vaccination, and personally responsible for the deaths of babies whose mothers embraced homebirth midwifery after you needlessly scared them about the “dangers” of hospital birth.

Perhaps you think that your words are not particularly meaningful, just a way to sell articles and books, and draw internet traffic. Perhaps you consider them a proud defense of your own mothering choices. After all, you never face the inevitable result; you never have to sit with deathly ill children in ICUs; you never have to attend the funerals where they put the tiny white coffins of the babies who die at homebirth into the ground. But when you put words out into the public space, you bear moral responsibility for the consequences.

I realize that your understanding of science is poor at best. You have no understanding of immunology, virology and statistics. You are shockingly ignorant about everything from the dangers of childbirth to the causes of autism. Hence your “warnings” are sincere. But sincerity doesn’t prevent life threatening illness, and it certainly won’t bring babies and children back from the dead.

You potentially HURT and KILL children, Jennifer Margulis, and that’s why I want to debate you.

My desire is to protect babies and children, and therefore, I consider it an unpleasant, but morally necessary task to eviscerate your arguments and publicly show you up for the foolish, dangerous woman that you are. The fact that I personally have no respect for you is irrelevant. Other people do, and, as a result, they risk the lives and health of their children. I want to put a stop to it and I think that I can.

Obviously, you are never going to agree to a debate. You recognize that your arguments WOULD be eviscerated, and you WOULD be held up for public ridicule if you participated in a debate. Therefore, after no doubt carefully mulling how to publicly appear to agree to a debate that you can never let happen, you suggested debating live on television, which, as you know, is about as likely to happen as debating live on Mars. I doubt many people are fooled by your sophistry.

You are no different than Henci Goer, Jennifer Block and every other homebirth advocate I have offered to debate. You may not know much, but your survival instincts are keen. Even you (and they) know that your arguments would not stand up to scientific scrutiny. That’s why the natural habitat of a homebirth blogger is her own website and Facebook page, where she can control any debate by deleting inconvenient facts and keep her followers thoroughly in the dark, while simultaneously congratulating them on being “educated.”

The real question for you, Ms. Margulis, is whether you are willing to publicly own the nonsense that you promote as truth. Although I would prefer to eviscerate your claims, I will probably have to settle for the consolation prize of pointing out that you aren’t willing to face someone with actual knowledge of science in an open debate.

For now, I guess that will have to do.

I love my job. I really do!

In what other job do you find people stepping forward to make fools of themselves so you can write about it?

Consider this from anti-vax clown Jennifer Margulis (you can click on the image to see it full size):

Margulis writes on her Facebook page:

A midwife who just requested my friendship on Facebook pointed out that I made the hit list of a notorious internet troll yet again! I am in good company with Ricki Lake and Jen Vbacfacts Kamel. I’ve had half a dozen friend requests today and three times as many new LIKES on Business of Baby. Thank you to this woman-hater for her ad hominem attacks against me. Her smear campaign is backfiring…

I guess there are blog “affirmations” just like there are birth affirmations and in both cases, saying it over and over again does not make it true.

My campaign against the mistruths, half truths and outright lies of the natural childbirth movement has never been more successful. I’ve never had more traffic. I’ve never had more requests for background help on mainstream media articles. I’ve never had more requests for interviews. I’ve never had so many private emails of thanks.

Margulis, who purports to be a professional journalist, is apparently thrilled to be included with Ricki Lake, a washed up talk show host, and Jen Kamel, a layperson who has the same amount of obstetric/midwifery training as both Margulis and Lake: NONE!

Hey, Jennifer, what are you going to do with all your Facebook likes for your book, currently ranked #297,043 on Amazon, and eviscerated by Annie Murphy Paul The New York Times Book Review? Oh, right, those likes are worthless.

From the NYTimes review of Margulis’ book:

Inaccurate or inflammatory statements are repeatedly reproduced without adequate substantiation or comment from the other side… Margulis’s treatment of scientific evidence is similarly unbalanced… [U]ltrasound exams of pregnant women may be responsible for rising rates of autism among their children, according to “a commentator in an online article.” This anonymous individual has “used ultrasonic cleaners to clean surgical instruments (and jewelry),” which apparently qualifies him or her to offer an opinion on how the vibration of ultrasound waves may be causing the developmental disorder: “Perhaps this vibration could knock little weak spots in myelin sheeting of nerves or such, I don’t know.”

Amy Wong of the Oregonian offered an equally cutting review:

Margulis builds her argument mostly on individual parents’ anecdotes, without providing context for whether they represent common experiences. Many of the anecdotes seem to have been selected purely for their shock value. And she frequently describes in detail how mothers suffered at the hands of doctors or nurses apparently without having sought out the doctors or nurses for verification, comment or context. This is not journalism.

But what’s especially notable about Margulis’ wishful thinking is the rogues’ gallery of “birth workers” who rushed to join her. They condemn themselves by the company they keep, including Robert Biter, who had his medical license revoked after 7 separate findings of malpractice, including the death of a baby at homebirth.

That got me thinking that there should be a Natural Childbirth Hall of Shame. It will take a while to compile the names of the many people who should be in it, but it’s never too early to think about the design.

There should be one wing for the lay people who present themselves as “experts” on childbirth, like Margulis, Lake, Kamel, and Henci Goer, among others. There should be another wing for those “birth workers” who have been persecuted for no better reason than because they presided over the births of a bunch of dead babies, including Biter, Ina May Gaskin (she deserves her own private alcove), Rowan Bailey, Christie Collins, Gloria Lemay, and all the “Sisters in Chains.” There should be a special section for organizations that profit from disseminating misinformation like Lamaze International, and other childbirth lobbying organizations.

And the courtyard should be set aside for the Midwives Alliance of North America, highlighted with a plaque in honor of MANA Liar-in-Chief Melissa Cheyney.

Jennifer Margulis has gone from journalist to joke, because of her endless stream of nonsense. Perhaps if she spent more time learning science, and less time worrying about me, she wouldn’t be one of the leading candidates for a spot in my Natural Childbirth Hall of Shame.

We’ve all suspected it. We’ve all seen the homebirth photos of hideously blue babies given high Apgar scores by homebirth midwives. Now comes confirmation that Apgar inflation is rampant among homebirth midwives.

In a new paper, Justified skepticism about Apgar scoring in out-of-hospital birth settings published in The Journal of Perinatal Medicine, Grunebaum et al. looked at 13,830,531 singleton term deliveries delivered from 2007 to 2010 in a hospital, a birthing center, or at home by either a physician, a CNM, or another midwife, and who had a 5 min Apgar score documented.

They found:

Newborns delivered by other midwives or certified nurse midwives (CNMs) in a birthing center or at home had a significantly higher likelihood of a 5 min maximum Apgar score of 10 than those delivered in a hospital [52.63% in birthing centers, odds ratio (OR) 29.19, 95% confidence interval (CI): 28.29 – 30.06, and 52.44% at home, OR 28.95, 95% CI: 28.40 – 29.50; CNMs: 16.43% in birthing centers, OR 5.16, 95% CI: 4.99 – 5.34, and 36.9% at home births, OR 15.29, 95% CI: 14.85 – 15.73].

This is both surprising and important since the Apgar score is not discretionary. There are strict criteria for assigning Apgar scores, as the chart below demonstrates, and we would expect only a very few Apgar scores of 10 regardless of setting because normal neonatal physiology means that most babies will have blue extremities for a significant amount of time after birth.

As the authors explain:

Our study shows an inexplicable bias of high 5 min Apgar scores of 10 in home or birthing center deliveries. Midwives delivering at home or in birthing centers assigned a significantly higher proportion of Apgar scores of 10 when compared to midwives or physicians delivering in the hospital. Studies that have claimed the safety of out-of-hospital deliveries by using higher mean or high cut-off 5 min Apgar scores and reviews based on these studies should be treated with skepticism by obstetricians and midwives, by pregnant women, and by policy makers.
The continued use of studies using higher mean or high cut-off 5 min Apgar scores, and a bias of high Apgar score, to advocate the safety of home births is inappropriate.

That’s a nice way of saying that homebirth midwives are either incapable of accurately assigning Apgars scores or deliberately inflating them.

Interestingly, a homebirth midwifery executive has also noted this inexplicable bias and ascribed a similar cause.

Melissa Cheyney, Liar-in-Chief of the Midwives Alliance of North America (MANA) in her role as Director of Research has invoked the incompetence of homebirth midwives in an effort to dismiss previous studies that have demonstrated an increased death rate at homebirth over comparable risk hospital birth. In Cheyney’s recent bizarre opinion piece in the Lamaze journal Birth: Issues in Perinatal Care alleging a “crusade” against homebirth, she writes:

There appear to be real differences between how physicians and home and birth center midwives perceive and report Apgar scores at the edges of the Apgar spectrum. Physicians are more likely to report fine gradations of either very low or very high Apgar scores, whereas home and birth center midwives are more likely to report Apgar scores of 0 or 10 more absolutely.”

In other words, Cheyney is insisting that homebirth midwives aren’t presiding over more deaths, they’re just stupid. Homebirth midwives deliver babies that are either better or deader than those delivered in hospitals because they are can’t accurately assign Apgar scores. But the reality is that there are no “fine gradations” of Apgar scores; there is no discretion in assigning Apgar scores of 0 or 10; and there are no differences in “perception” of neonatal death or a vigorous, completely pink newborn.

As poorly educated and poorly trained as I believe homebirth midwives to be, even I cannot imagine that they are mistakenly diagnosing babies as dead when they are not dead. And the only remotely plausible reason for more Apgar scores of 10 among a population that has a greater number of deaths than expected is rampant inflation of Apgar scores by homebirth midwives.

The bias of tendency of homebirth midwives to assign higher Apgar scores than warranted was anticipated by Virginia Apgar herself in recommending that the Apgar scores be determined by someone other than the person who delivers the baby:

Dr. Apgar herself anticipated the potential for bias in scoring when she stated: “ it is strongly advised that an observer, other than the person who delivers the infant, be the one to assign the score ” and “ … experience has demonstrated that the person delivering the infant should not be the one to assign the score. He or she is invariably emotionally involved with the outcome of the delivery and with the family, and cannot or unconsciously does not make an accurate decision as to the total score ” .

And indeed, the key difference between the assignment of Apgar scores at home and in the hospital is that at homebirth the midwives assign the Apgar score whereas the hospital nurse assigns the score in the hospital, eliminating the tendency to artificially inflate the score.

The authors conclude by calling into doubt the results of homebirth studies that use mean Apgar scores to “demonstrate” the safety of homebirth:

… [S]tudies that have claimed the safety of out-of-hospital deliveries by using higher mean or high cut-off 5 min Apgar scores and reviews based on these studies should be treated with sustained skepticism by obstetricians and midwives, by pregnant women, and by policy makers. The continued use of studies using higher mean or high cut-off 5 min Apgar scores and a bias toward high Apgar score to advocate the safety of home births is inappropriate.

There is simply no question that homebirth midwives are biased in assigning Apgar scores. Why? Cheyney says that it’s because homebirth midwives are stupid. Grunebaum implies it is because homebirth midwives don’t tell the truth.

Idiots or liars, take your pick, but either way, homebirth midwives are incompetent practitioners. It is hardly surprising then that all existing research on American homebirth (including MANA’s own statistics), all state statistics, and all CDC national statistics shows that homebirth with a non-nurse midwife dramatically increases the risk of neonatal death.

Thinking about homebirth? Perhaps you should think again.

Are you gullible?

Would you take flying lessons from a stewardess?

Would you get legal advice from legal secretary?

Would you take cardiology advice from someone whose qualifications are 3 heart attacks?

If you’re getting your childbirth advice from Jen Kamel and her fellow birth blogger buffoons, you ARE gullible. What’s worse is that you may be so gullible that you are actually paying for that “advice” in the form of “work shops,” courses, web subscriptions, etc. And what’s even worse is that your babies may be paying for your gullibility as you risk (and lose) their lives by following the bloggers’ “advice.”

Who are the birth blogger buffoons? They are women with no training in obstetrics who have the temerity to believe that they know more about obstetrics than obstetricians. They are walking, talking illustrations of the Dunning-Kruger effect, which Wikipedia defines as:

Unskilled individuals suffer from illusory superiority, mistakenly rating their ability much higher than is accurate. This bias is attributed to a metacognitive inability of the unskilled to recognize their ineptitude.

How can you identify the birth blogger buffoons? In most cases, it’s pretty easy. All you need to do is consider their role in the provision of obstetric care.

Doulas are the equivalent of stewardesses; their role is the comfort of clients (passengers). Doulas don’t know any more about childbirth than stewardesses know about safely flying the plane.

Childbirth educators are the equivalent of legal secretaries. The job of a legal secretary is to assist the lawyer; they may know legal terminology but they are unqualified to practice law or to evaluate those who do. Similarly, childbirth educators may know obstetric terminology, but they are unqualified to practice obstetrics or midwifery and incapable of evaluating those who do.

Lay birth bloggers are like lay people everywhere. They have no specialized knowledge, only their own experience, which they often don’t fully comprehend, and which may be irrelevant to your personal situation. Looking to a woman like Jen Kamel for advice on VBACs simply because she had a successful VBAC is like taking oncology advice from someone who survived cancer. It is confusing luck for knowledge.

There are many, many birth blogger buffoons out there, but some are more popular than others. Some of the biggest birth blogger buffoons, in addition to Jen Kamel, are:

Ricki Lake of The Business of Being Born and My Best Birth

January Harshe of Birth Without Fear

Gina Crosly-Corcoran of The Feminist Breeder

Doula Teri Shilling, former president of Lamaze International, of My OB Said What??!!

The childbirth educators of the Lamaze blog Science and Sensibility

The folks at ICAN (International Cesarean Awareness Network)

Journalist Jennifer Margulis

This is hardly an exhaustive list; there are many more.

How do you recognize a birth blogger buffoon? By what they are selling and by the fact that they are selling it. Their primary product is always distrust of modern obstetrics. Although modern obstetrics is probably the most spectacularly successful of all the many successful medical specialties (dropping the neonatal mortality rate 90% and the maternal mortality rate 99% in the past 100 years), the birth blogger buffoons never acknowledge the many, many, many lives saved by obstetricians each and every day. The secondary product is the services, books, workshops, and paid advertising from which they profit. They are not giving their “advice” out of the generosity of their hearts; they make money from it.

For example, both Jen Kamel and Gina Crosly-Corcoran run VBAC Workshops and charge steeply for them. You have to be some kind of stupid to spend money on a doula VBAC workshop from someone who has no experience managing VBACs, grossly deficient knowledge of the risks and benefits, and no obstetric knowledge at all. On the gullibility scale, that’s right up there with paying a stewardess for flying lessons!

I think this person sums it up best:

Every practitioner … has likely witnessed the problems that occur when lay people cross the line of giving information and feel competent to dispense actual medical advice despite the absence of any clinical training or education… A doula is not a medical expert, and medical advice is outside a doula’s area of practice.

My objective is to issue a warning: There are a lot of people out there who have no idea what they are talking about. And it is downright shocking to me how many parents and professionals are willing to just accept something as truth simply because they read about it on a blog … A little bit of knowledge is not enough to understand any complex subject including post-cesarean birth options.

Who said it? Why Jen Kamel, of course. Now if we could only get her to take her own advice.

Karma is a bitch.

Jen Kamel of the loosely named blog VBACFacts, a lay person with a very poor grasp of obstetrics, decided to do a hatchet job on a wonderful post by Doula Dani.

Danielle wrote about vaginal birth after cesarean (VBAC), Jen’s supposed area of “expertise.” Being the deeply conscientious person that she is , she gave Jen the opportunity to participate in the post. Jen turned her down, but when the post was published, she savaged it, first in private and then publicly by reprinting the private conversation without permission.

Jen titled her acid post The Dangers of Birth Blogs, and had this to say about Danielle:

Every practitioner and birth professional reading this has likely witnessed the problems that occur when lay people cross the line of giving information and feel competent to dispense actual medical advice despite the absence of any clinical training or education. (For specific examples of what this looks like, click on the third Facebook post above.) A doula is a childbirth support specialist, skilled at helping families navigate labor and birth in a way that fits each family’s needs, values and risk tolerance. A doula is not a medical expert, and medical advice is outside a doula’s area of practice.

Now I don’t name this doula or link to her blog because my objective is not to publicly shame her or to direct people to her blog. While I use my experience with this doula as a example, this is about the bigger picture.

My objective is to issue a warning: There are a lot of people out there who have no idea what they are talking about. And it is downright shocking to me how many parents and professionals are willing to just accept something as truth simply because they read about it on a blog … or writes about it on Facebook … A little bit of knowledge is not enough to understand any complex subject including post-cesarean birth options.

The irony, of course, is that Jen is describing herself. She is a lay person who “routinely crosses the live of giving information and feel competent to dispense actual medical advice despite the absence of any clinical training or education.” She has a little bit of knowledge about VBACs but “not enough to understand any complex subject including post-cesarean birth options.” And like Jen, I marvel at “how many parents and professionals are willing to just accept something as truth simply because they read about it on a blog” … like, say, VBACFacts.

Jen’s post is as clear as mud. It is extremely difficult to read and understand. But I did understand this, which Jen posted in the comments and on the associated Facebook post:

If there is something that I have said above that is inaccurate, please let me know.

So I let her know.

Jen criticized the use of the appalling MANA HBAC data to demonstrate that attempting a VBAC at home has a hideous death rate:

… You have to know that issues with the MANA mortality data. That collection of data is insufficient to accurately measure mortality. 1000 TOLACs [trial of labor after cesarean].

When Danielle points out that the data is not insufficient, Jen doubles down:

It is laughable that she makes this statement. Anyone who claims that 1000 labors is sufficient to measure maternal or neonatal mortality rates in America has no idea what they are talking about. It is simply too small of a sample size.

Jen is withering:

how much of my time should I give you to work on your piece?

2 hours?

3 hours?

7 hours?

I mean… I want to help you, but…

And I’ve already given you a line by line feedback.

And:

As someone with a website, you are under an obligation to be ethical, clear, and transparent. When you make conjectures like that, when you make leaps or tie two events together that have not been clearly connected per research, you are not being clear. It certainly makes for pretty dramatic reading but it’s not accurate.

So the question is: do you want to go for dramatic or do you want to go for factually accurate? Because sometimes factually accurate is a little bit more boring, frankly. All depends on what your objectives are. The truth? Or some other agenda?

And:

Is it good science to take an pretty solid figure (hospital mortality rates) and compare it to a figure found in a study that is not powered to measure mortality rates and then make a conclusion? Perhaps for someone reaching for an agenda, yes. But we have to be honest. And the honest answer is, the MANA data is not powered to measure mortality. They acknowledge that in the narrative. End of sentence. You cannot take this data and wave it around as a strong piece of evidence on the mortality rates of home VBAC.

Too bad Jen is completely, totally, utterly wrong.

I explained to Jen on her Facebook page why the MANA data is adequate to draw conclusions. I explained why you can’t just eyeball the data to determine if it is adequate (as she acknowledged that she did), and there is a statistical test for power. I explained that both sample size AND effect size determine power, meaning that a large effect requires a much smaller dataset to be adequately powered than a small effect and the difference between the HBAC death rate and the hospital death rate is quite large. She countered by claiming that MANA thinks the data is underpowered, as if that means anything.

But apparently, the more she thought about it, the more she realized she had made some serious errors. So she did what any natural childbirth blogger does when confronted with an error: she deleted the evidence. She deleted her blog post (the link above is the cached version) and she deleted the Facebook post where she is shown to be wrong, as well as multiple other Facebook posts that referred her withering hatchet job.

She forgot to take down one of her Facebook posts, the most ironic one of all.

The text on the illustration is cut off. It reads:

Science:
If you don’t make mistakes, you’re doing it wrong.
If you don’t correct those mistakes, you’re doing it really wrong.
If you can’t accept that you’re mistaken, you’re not doing it at all.

I propose that we add the following line just for Jen:

If you hide the evidence that you were mistaken, you are a very dangerous birth blogger.

And, Jen, one more thing:

If you don’t apologize publicly to Danielle for that underhanded, vicious, ignorant hatchet job, you are contemptible.

Natural childbirth and homebirth advocates love to bemoan the “cascade of interventions.” Their theory is that every intervention leads to more interventions until finally a C-section is necessary. The implication is that if the first intervention had been withheld, the mother would have gone on to have an uncomplicated vaginal delivery of a healthy baby. But like so much of natural childbirth and homebirth advocacy, the dreaded cascade of interventions is made up crap, designed to demonize tests and procedures that the natural childbirth industry cannot provide or profit from.

In fact, in many cases, the opposite is true. Many interventions make it LESS likely that a mother will have a C-section, not more. For example, there is a growing body of evidence that induction of labor leads to a LOWER C-section rate than awaiting spontaneous labor. A large, comprehensive study just published in the Canadian Medical Association Journal provides the most compelling evidence yet that induction lowers the risk of C-section.

The study is Use of labour induction and risk of cesarean delivery: a systematic review and meta-analysis by Mishanina et al.

The authors explain:

Although induction of labour has been criticized for an associated increased risk of cesarean delivery, recent studies have shown that there are fewer cesarean deliveries with induction than without it. However, the findings have not had much impact on practice, in part because the systematic reviews investigated subsets of induction and included few randomized controlled trials (RCTs), and because observational data in a cohort study had risk of confounding. Consumer organizations, guidelines and textbooks have given contradictory information about cesarean risk, which can lead to confusion over decision-making, particularly given a desire to support normal birth in the face of increasing cesarean rates worldwide…

How did the authors investigate the issue?

We searched 6 electronic databases for relevant articles published through April 2012 to identify randomized controlled trials (RCTs) in which labour induction was compared with placebo or expectant management among women with a viable singleton pregnancy. We assessed risk of bias and obtained data on rates of cesarean delivery. We used regression analysis techniques to explore the effect of patient characteristics, induction methods and study quality on risk of cesarean delivery.

The literature review led to 157 papers encompassing 31,085 women.

What did they find?

Overall, … the risk of cesarean delivery was lower with labour induction than with expectant management (pooled RR 0.88, 95% CI 0.84–0.93)…

In the subgroup analysis by method of induction, 4 methods were associated with a significant reduction in risk of cesarean delivery: prostaglandin E2 (RR 0.90, 95% CI 0.84–0.96; I2 = 0%), misoprostol (RR 0.62, 95% CI 0.48–0.81; I2 = 0%), alternative method (RR 0.66, 95% CI 0.50–0.86; I2 = 60.7%) and mixed method (RR 0.81, 95% CI 0.70–0.95; I2 = 0%).

Subgroup analysis by indication for induction showed a universal reduction in risk of cesarean delivery. Induction without a medical indication provided was associated with risk reduction of 19% (RR 0.81, 95% CI 0.70–0.93; I2 = 13.5%). When we looked at risk of cesarean delivery by gestational age, we found statistically significant reductions in risk with labour induction in term and post-term pregnancies, but not in preterm pregnancies.

In the analysis by definition of induction, risk of cesarean delivery was significantly lower when the definition included cervical ripening alone or combined with stimulation of uterine contractions than when it included uterine stimulation alone. The analysis by cervical status showed a 13% reduction in risk of cesarean delivery if the cervix was unfavourable at induction (RR 0.87, 95% CI 0.81–0.94; I2 = 1.4%) and no difference in risk if the cervix was favourable (RR 0.83, 95% CI 0.60–1.14; I2 = 0%).

The risk of cesarean delivery was reduced in both high- and low-risk pregnancies.

In other words, induction lowered C-section rates for nearly every possible indication including NO indication, using every one of the most common agents, for both term and postterm pregnancies, in both high and low risk pregnancies, and even if cervical status was unfavorable.

The authors include a forest plot that graphically illustrates the results:

In addition, outcomes were better with induction:

Analysis of adverse outcomes showed a lower risk of fetal death and admission to neonatal intensive care unit associated with labour induction than with expectant management. No impact on maternal death was shown.

The authors conclude:

Our meta-analysis has provided a robust answer to the disputed question of risk of cesarean delivery associated with induction of labour. Women whose labour was induced were less likely than those managed expectantly to have a cesarean delivery. In addition, the risk of fetal death and admission to neonatal intensive care unit were decreased in the induction group. Our findings have implications for guidelines and the practice of obstetrics, and are reassuring for mothers, midwifes and obstetricians.

So it seems that if you want to reduce your risk of C-section, one of the most effective things that you can do is to have an induction of labor.

Ironic, no?

The mind is an amazing thing. There is really no limit to the human capacity for shedding responsibility for hurting and even killing others. VBAC advocates seem to be particularly adept at this form of denial.

Consider the following story of a baby who died a preventable death at  a VBA2C. The short version:

The mother had a terrible obstetric history, 3 preterm deliveries, one vaginal, a C-section for preterm breech and a C-section for bleeding placenta previa. She was a horrible candidate for VBAC, with a low chance of success and a high chance of rupture. No hospital would accept her for VBA2C because the risk of rupture and death was too high. She decided to labor at home and show up at the hospital fully dilated. Unfortunately she did have a catastrophic uterine rupture and the baby did die EXACTLY as she was warned. Nonetheless, several months after the fact, she is still babbling that this was both unpredictable an unsurvivable. She is flat out wrong on both points.

This is the way she tells the story on a VBAC support website:

Her terrible obstetric history

My first daughter was a PPROM at 31.5wks, born natural vaginal in about 4 hrs post rupture . No augment or meds to stop labor. Was amazing and despite 24days in NICU she is amazing!

My next baby we were so freaked out about prematurity … [A]t 32.5wks .. I was having contrax, we went in for steroids and “stop meds”. During this antepartum stay I was bullied and badgered and harassed. My breech baby girl also had ‘low fluid’ … [They] told us if we didn’t surgically deliver that day my daughter would die. BIRTH TRAUMA occurred for me and major PPD 9months after due to horrible 21day NICU stay and crap bonding (despite steroids her lungs were crap for a 34week girl) …

… 3rd daughter was bound and determined to get to ten! birth vaginally! no bullying allowed! Alas, due to csection, a complete centered placenta previa. Made it to 35weeks when a bleeding placenta forced surgical delivery. Healing birth don’t get me wrong but hospital policy dictated an antepartum stay for a few days during which I was asked to “presign” consent etc and had to fight doctors … my hubby and I even had social workers sent in for us because my RN (who was 8months pregnant) couldn’t understand that a healthy baby was NOT my only goal outcome. (my emphasis)

Three times this mother was in danger of a baby dying. Once she was even in danger of dying herself. Instead of being grateful, she was angry at not having a specific birth experience. After all, a healthy baby was NOT her only goal.

Her interpretation of being told that she was not a suitable candidate for VBA2C:

We had been working with a CNM, OB, MFM doc all on the same page: the two closest hospitals WOULD NOT let me labor without being bullied and badgered for a csection. I was told to come “ready to deliver” which to me meant to labor at home for as long as possible.

Imagine that; they bullied her by telling her that the risk of her baby dying was high. So instead of giving up her “experience” for a live baby, she decided to stay home until the hospital would be forced to let her deliver vaginally.

She and her doula missed the signs of uterine rupture. After multiple hours of regular contractions she felt a “kick” and then continuous pain:

She and I couldn’t differentiate contrax as I was feeling almost tetanic but still very much cramping sensations

Her grossly irresponsible CNM let her labor at home alone and arrived to find that the baby was dead.

 [The rupture] was catastrophic. But my uterus did its job. The scar opened, birthed a baby and placenta and it shut down the bleeding. My son most likely died within the first 10 minutes though we will never know and for that I am grateful. My CNM arrived around midnight as planned and she couldn’t find baby’s heartbeat. After that I went into shock quite promptly and was eventually ambulance transferred for emergency surgery where my son was removed from my abdomen (he was up by my spleen) and 2 liters of blood was removed from my peritoneal cavity. I needed one blood transfusion but my uterus had stopped bleeding completely so the Dr stitched the now small hole and left it in my pelvis. Though he commented “Never use it again!”

Let’s recap:

A woman with a terrible obstetric history was told that she was not a candidate for a VBA2C because the risk of uterine rupture and death of her baby was too high, even for hospitals that routinely handled VBACs. So instead she decided to labor at home, where a rupture would surely be a death sentence for her baby. Just as she was warned, she ruptured and the baby died. How does she justify the entirely preventable death of her son?

Had this happened in the hospital most likely it would not have given us a healthy or alive son. It was a quick rupture per the 3 OBs that were in the OR, like a popped balloon, not a slow tear. There was no predicting it though per our perinatologist, as it is not evidence based to measure scar thickness to TOLAC. We would most likely not have been presenting to a hospital this early in labor anyway, having not lost mucus plug or water breaking etc. And after a pregnancy so unlike all my others, with everything going our way, why would I have thought about rupture?

NO PREDICTING IT? The told her repeatedly that they would not oversee a VBA2C specifically BECAUSE they thought she would rupture.

Hospital birth would not have given us a health or alive son? That’s pure bullshit. Had she had a C-section prior to labor, her baby would be alive and healthy. Had she gone to the hospital and had a C-section at the first sign of labor, her baby would be alive and healthy. And the odds are high that if she had experienced the exact same rupture in the hospital, her baby would be alive and healthy. The ONLY reason her baby is dead is because she chose to martyr him on the altar of vaginal birth. She let him die.

But, as I say, the human mind is an amazing thing. She still hasn’t accepted responsibility for her choice.

We were given the statistics respectfully and it was our choice to make. Obviously the wrong one for my son but how were we to know?

How were you to know? BECAUSE THEY TOLD YOU!!!

There is at least a glimmer of awareness:

I do have more posts coming related to the birth and VBAC, specifically one called , “I Martyred My Son” but since it is highly political I am really working it to make it right.

But only the tiniest glimmer:

My story should not be taken as a scare tactic. I would still have made the same choice but wish we had the option to attempt this in the hospital. I will never know if we could have saved my son if given the opportunity to monitor him earlier.

But what we ALL know is that if she had agreed to a C-section, he would be alive, cooing, babbling, smiling at his older sisters, and instead he is DEAD! All the potential of a life that had limitless potential was snuffed out just because his mother wanted to experience a vaginal birth.

She martyred her son for her own birth “experience.” I’d like to know if it was worth it.

Natural childbirth and homebirth advocacy are based on mistruths, half truths and outright lies.

The biggest lie of all, the foundational lie of natural childbirth and homebirth, is the idea that birth is inherently safe. I’ve been writing for years that childbirth is the single most dangerous day of the 18 years of childhood. Now a new paper published in the British Journal of Obstetrics and Gynecology shows that birth isn’t simply the most dangerous day of childhood; it is the most dangerous day of a 90+ year lifespan.

The paper is The dangers of the day of birth. One of the authors wrote about it at his personal blog.

The authors point out that most people think that childbirth is safe:

… these risks are generally perceived to be low, and as a result many parents resent the intrusiveness of hospital birth, fetal monitoring, and other recommendations…

Much of the risk of childbirth remains concentrated in a relatively short period: the day of labour and delivery. In addition, when death occurs so early in life it results in more life years lost on average than when death occurs at an older age.

We speculated that expressed on a daily risk scale, instead of as per thousand births, childbirth risks would appear very different. We aimed to calculate the risk of dying on each day of your life, and compare these risks with other activities or events that an individual may encounter. This information would then be used to calculate the loss of life expectancy sustained with death occurring on the day of birth.

What did they find?

Even with modern obstetric practice the risk of a baby dying on the day of its birth in the UK is greater than the average daily risk of death until the 92nd year of life. We have shown that this risk is comparable with many other high-risk activities, and results in many life years lost.(my emphasis)

So childbirth isn’t safe for babies. It is quite dangerous, comparable to the risk of death for the average 92 year old adult and comparable to the risk of death for those facing major surgery. The graphic representation is impressive:

The risk in the US is even higher as a result of a higher rate of risk factors and a lower rate of health care access than in the UK.

And that’s the risk when the baby has access to immediate life saving care. The risk at homebirth is higher still.

When natural childbirth or homebirth advocates tell you to trust birth, show them the graph, and see what they have to say then.

If they still tell you to trust birth, you have learned that you should never trust them.

I’m pretty confident that over the next several decades we will reduce the risk of childbirth in dramatic ways. After all, we understand the problems that we face; it’s just a matter of creating the technology that will provide the answers we need.

We know, for example, that the biggest threat to babies is lack of oxygen during labor. We don’t have a way of directly measuring the amount of oxygen that the baby is receiving so we are forced to approximate using existing technology, measuring the fetal heart rate instead. Because the fetal heart rate provides only an indirect, and often inaccurate, picture of fetal oxygenation, obstetricians end up performing unnecessary C-sections for presumed fetal distress that wasn’t distress at all. When we can accurately measure the amount of oxygen in the fetal blood stream, the only C-sections done for fetal distress will be necessary C-sections and the C-section rate will drop dramatically.

The history of obstetrics over the past 100 years is a history of identifying specific risks and then creating treatments to abate those risks or preventive strategies to remove the risks entirely. For example, pre-clampsia/eclampsia has always been a leading killer of mothers and babies. We still don’t understand the cause of the disease, but we do understand the warning signs and we have created treatments and preventive strategies that have dramatically decreased the death rate of pre-eclampsia/eclampsia for mothers and babies.

The evolution of obstetrics, and the dramatic decrease in death rates that have resulted, are a result of technology. In other words, the less we trust birth, and the more we trust technology, the fewer babies and women die. It is simply a matter of time before we have better technology that will help us achieve lower rates of death and injury by more accurately targeting treatments and preventive measures.

The real question for those who care for pregnant women is this: what do we do in the meantime?

When we have imperfect information, and when the lives of babies and mothers are on the line, should we err on the side of caution or err on the side of risk?

The answer to that question delineates the central difference between obstetricians and homebirth advocates. Obstetricians err on the side of caution. They’d rather do perform unnecessary tests, procedures and C-sections in an effort to prevent all preventable deaths. Homebirth advocates err on the side of risk, either by pretending there is no risk (“trust birth”), by ignoring risk (refusing routine tests and interventions), or by treating complications when they happen instead of preventing them (“the hospital is only 10 minutes away”). They’d rather risk preventable deaths than submit to anything that was unnecessary in retrospect.

When homebirth advocates lament obstetricians playing the “dead baby card,” they are making fun of doctors who would rather err on the side of caution. And they are implicitly advising women to err on the side of risk. They basically tell women to gamble the lives of their babies because the chances of disaster are relatively small.

Obstetricians are the equivalent of the people who tell you to board up your windows at the approach of a hurricane, reasoning that boarded up windows won’t break in the event that they are stressed to their limits by wind gusts. Homebirth advocates are the people who tell you not to board up your windows on the theory that you can save lots of time, effort and money by betting that your personal windows are not necessarily going to break in a hurricane, since the odds of a specific set of windows breaking is fairly low. Those who board up their windows are erring on the side of caution. Those who “trust hurricanes” are erring on the side of risk.

Obstetricians are the equivalent of the people who tell you to wear a helmet when riding riding a bicycle, reasoning that people who wear helmets are much less likely to suffer brain injuries if the motorcycle crashes. Natural childbirth advocates are the people who protest helmet laws on the theory that most of the time you won’t get into a crash and it’s so much more enjoyable to feel the wind rushing through your hair. Helmet laws err on the side of caution; those who protest helmet laws err on the side of risk.

So if you are thinking about homebirth, think about this: the day of birth is the single most dangerous day of the entire 18 years of childhood; the risk of death is never higher. Whether you wish to acknowledge it or not, childbirth puts your baby’s life on the line.

The question you need to ask yourself when contemplating the risk to your baby is:

Do you want to err on the side of caution and head to the hospital, or would you rather stay home and err on the side of risk?