The British press is filled today with the latest installment of findings from the Birthplace Study, Cost effectiveness of alternative planned places of birth in woman at low risk of complications: evidence from the Birthplace in England national prospective cohort study published in today’s edition of the British Medical Journal. Although reporters are faithfully trumpeting the press release claims, the real findings are far more nuanced and far less definitive.

To understand why the Birthplace study does not and could not show that homebirth is more cost effective, it is helpful to look at the more detailed version of the findings available here. But first, we need to understand what “cost effectiveness” actually means.

Obviously any time you provide less care or lower quality care, the cost is going to be reduced. Therefore, homebirth is always going to cost less. The real issue is whether outcomes cost less, more or the same when you provide less care. But the study only looked at short term costs, and as the authors acknowledged, it is long term costs that are potentially enormous.

… With regards to the baby, a change from planned place of birth in an OU [obstetric unit] to a non-OU setting will generate lower costs, but this is accompanied by uncertainty surrounding effects on adverse perinatal outcomes…

That’s because:

The limited time horizon of the study meant that the follow up of outcomes for both mother and the baby did not extend beyond the time period of labour care, or higher level postnatal or neonatal care when this was received. Serious adverse outcomes can result in associated life-long health and societal costs, as shown by the size of damages paid in obstetric litigation cases, which represent a substantial cost to the NHS. Less serious, but more frequent, morbidities associated with labour and birth and its management affect women and babies. Follow up over weeks or longer to monitor recovery, or a future assessment of the outcomes for mothers and babies at a later date, would shed more light on long term cost- effectiveness.

In other words, the study CAN’T tell us about cost effectiveness since it does not take into account the largest costs, the costs of caring for a child injured during birth and the massive costs associated with legal settlements for babies who were injured or died.

There is an additional reason why the Birthplace study cannot tell us if homebirth is cost effective. The study population does not reflect the real world population of women who choose homebirth.

As I wrote back in December:

… The list of study exclusion criteria was far more restrictive than the actual exclusion criteria for homebirth in the UK. Therefore, a substantial proportion of the women who actually had a homebirth were excluded from the study even before it began. Of the 18,269 low risk women planning homebirth at the start of the study, 1346 (7.4%) were excluded from the study despite the fact that they went on to have a homebirth under the auspices of the National Health Service.

The bottom line is that the Birthplace study does NOT, indeed cannot, show that homebirth is more cost effective. All it shows it that among women who meet eligibilty criteria far more strict than the actual criteria for homebirth in the UK, homebirth is cost effective in the short term. Of course, the short term is irrelevant since it is in the long term that the true costs are incurred.

It is my impression that the authors of the Birthplace study really, really, really want to put the stamp of approval on a goverment policy to support homebirth that was approved before adequate safety data were available. In terms of cost effectiveness, however, the results are so restricted as to be virtually meaningless.

It’s difficult to imagine a more perfect example of the moral bankruptcy of professional homebirth advocates than their rush to “support” killer midwives.

In the wake of the preventable death of their son Magnus, Sarah and Jarad Snyder are suing The Greenhouse Birth Center.

You can read the story of Magnus’ birth and death at Hurt by Homebirth, and you can read about the lawsuit here.

As is inevitable in the aftermath of any death at the hands of homebirth midwives, no matter how egregious the malpractice, a Facebook group has been set up to support … no, not the parents who lost a precious infant … but the midwives responsible for the loss.

Among the homebirth celebrities lending their support is Ina May Gaskin. Magnus’ mother Sara has some questions for Gaskin:

Dear Ina May Gaskin:

Could you describe the role of a midwife in your own words, specifically during labor/birth?

How would you define the word “ethical”?

Do you believe that all doctors are ethical? Teachers? Religious Leaders?…Do you believe all midwives are ethical?

Do you believe midwives ever make mistakes?

What do you believe should happen when a midwife makes a mistake?…one that… costs someone his or her life?

What do you believe should happen when a doctor makes a mistake?…one that costs someone his or her life?

Do you believe that lying to cover up mistakes is ever appropriate?

What should happen when a midwife operates outside her scope of practice and purposefully takes on “high risk” birth without informing the parents she is doing so?

Why are families who share their less than perfect experiences demonized instead of helped, or God forbid, listened to in an effort to improve practice?

Do you know ANYTHING about the details of my labor and delivery? The care we did and did not receive? Have we ever corresponded?

Do you have any understanding at all of the confidence and trust we had in our midwives as competent caregivers before this preventable tragedy took place?

How would you define the word “betrayal”?

That’s what our midwives gave to us and that is what you too are doing in supporting them blindly. I am so disappointed, that you wouldn’t better know whom you are supporting and demand better as the leadership in this movement. The biggest regret of my life is ever having trusted a midwife with the well being of my child. How foolish am I to have thought you stood for something more honorable.

Most Sincerely,
Sara Snyder

Sara is much nicer than me. I have only one question for Gaskin:

How dare you reflexively support homebirth midwives without making any attempt to determine whether they are culpable for Magnus Snyder’s death?

I’d be happy to give her a forum on this blog to explain why anyone should take seriously those professional homebirth advocates who are so cynical and morally bankrupt that they think supporting negligent homebirth midwives is more important than whether babies live or die.

Lest you think that Gaskin is the only one, here’s a list of the other morally bankrupt professional homebirth advocates who don’t give a damn whether individual babies live or die:

Barabara Harper
Deborah Pascali-Bonaro
Jennifer Block
Pggy O’Mara
Geradine Simkins
and, of course, serial killer midwife Lisa Barrett.

I’m happy to extend my offer to them as well. How about it, ladies? Please explain to us why anyone should believe that professional homebirth advocates have any commitment to the safety and health of babies when you are so quick to support those who let babies die preventable deaths.

This is an object lesson in why the CPM should be abolished and why homebirth midwives should not be licensed. It makes no difference to them whether a baby lives or dies as long as their income stream is protected.

Lisa Barrett is getting a run for her money. Barrett, an Australian homebirth midwife, has presided over 5 preventable neonatal deaths in approximately 4 years. It only took Jerusha Goodwin and her colleagues at The Baby Place 10 months to rack up 3 entirely preventable neonatal deaths.

How do we know? Back in mid 2010 the state of Idaho decided to license homebirth midwives and creating a reporting process for bad outcome. No sooner did they create a reporting process than they started receiving reports of preventable neonatal deaths resulting from appalling negligence. The news story is here, but only the official documents can detail the true scope of the horror.

Death #1:

ii. On October ll, 2010, Respondent delivered N.H.‘s infant daughter, C.H., at The Baby Place…

iv. During the final stages of labor, C.H.’s fetal heart rate dropped significantly to 60 beats per minute.

v. Shortly after birth, Respondent failed to ensure that C.H.’s umbilical cord was clamped before a student midwife cut it. As a result, C.H. lost a significant amount of blood.

vi. The Baby Place‘s records documenting the birth of C.H. fail to state that C.H. was a nuchal cord delivery or that C.H.’s umbilical cord was not clamped before it was cut, which resulted in significant blood loss.

vii. On October 11, 2010, C.H. was transported by ambulance to the hospital. At the time of her admittance to the hospital. C.H. had “respiratory failure since birth” and “severe” hypoxic-ischemic encephalopathy. Additionally, C.H. had an initial pH of 6.5 with a base deficient of -30. C.H. died on October 25, 2010.

viii. Respondent failed to inform paramedics or physicians that C.H. was a nuchal cord delivery, that C.H.’s umbilical cord was cut before it was clamped, and that C.H. sustained significant blood loss as a result of the failure to clamp the umbilical cord. Additionally, Respondent failed to provide paramedics or physicians with relevant medical records or relevant details regarding the labor and delivery process.

Death #2:

ii. On August 9, 2011, Respondent delivered H.T.’s infant son, O.R., at The Baby Place.

iii. At the time of delivery, 0.R. was at least 42 weeks and one day in gestational age.

iv. Near the onset of labor, H.T. reported having “greenish” vaginal discharge. Additionally, when the spontaneous rupture of membranes occurred, there was meconium in the fluid and 0.R. was not born for another 19 hours.

v. H.T.’s labor was abnomrally protracted, as she was in active labor for approximately 48-and-a-half hours, the infant was at the plus 1 station for approximately nine hours, the pushing phase lasted approximately l0-and-a-half hours …

vi. During the afternoon of August 9, 2011, Respondent instructed H.T. and other midwives at The Baby Place to state that the pushing phase began at 3:00 p.m. despite the fact that H.T. actually started pushing at approximately 10:00 am. and continuously pushed until the time of birth
at 8:40 p.m.

vii. At the time of birth, O.R. was “limp, unresponsive and pale,” had meconium staining around the mouth, and had a heart rate of 80. Respondent then began resuscitation efforts but did so ineffectively, as O.R. was on a flat surface without the head tilted back and the mask was not properly sealed.

viii. The Baby Place waited approximately ll minutes after 0.R, was born to call paramedics.

ix. When paramedics anived at The Baby Place to transport O.R. to the hospital, they determined that he had an APGAR score of 2.

x. Respondent failed to provide a report of O.R.’s condition or progress to paramedics or hospital physicians. Respondent also failed to ensure that H.T. and 0.R.’s records from The Baby Place were transported to the hospital with O.R. Respondent first provided the hospital with the relevant medical records on August 12, 2011 at 4:32 p.m., which was three days alter O.R,’s birth and after O.R. died in the hospital.

xi. O.R. died at the hospital at approximately 3:41 p.m. on August 12, 2011. The autopsy stated that the cause of death was “anoxic brain injury secondary to prolonged vaginal birth complicated by meconium aspiration.”

Jerusha Goodwin’s mother Colleen, also a midwife, presided over death #3:

ii. R.R. is a Type 1 diabetic. Respondent provided care to R.R. without providing R.R. with written notice that she was required to obtain care from a physician for her diabetes as a condition to obtaining maternity care from Respondent. Additionally, Respondent did not obtain a signed acknowledgment fiom R.R. that she had received written notice of this condition for maternity care.

iii. On June 29, 2011, R.R. had flu-like symptoms and had been vomiting and had diarrhea throughout the day. These symptoms continued on June 30, 2011.

iv. During the labor process, the fetal heart rate frequently dropped to below-average levels and even dropped into the 80s. Respondent failed to document these below-average heart rates in The Baby Places’ records.

v. During the labor process, Respondent instructed R.R. to push when R.R. was not fully-dilated.

vi. During the labor process, Respondent provided R.R. with a one-page document explaining Group B Streptococcus (“GBS”), which recommended that “all women be tested for GBS at 35-37 weeks of pregnancy.” R.R. signed the form and waived the GBS test, but later stated that she “had no idea what [she] was signing,” as she was in a great deal of pain and was not provided with an adequate explanation of GBS.

vii. At 1:59 a.m. on June 30, 2011, Respondent called paramedics due to fetal heart rates that had decelerated to dangerous levels in the 80s. When the paramedics arrived at The Baby Place at 2:06 am., Respondent failed to ensure that R.R. was ready to be transported. Additionally, Respondent delayed paramedics from entering R.R.’s room for at least four minutes.

viii. Respondent failed to fully-cooperate with paramedics. She had to be asked questions multiple times before responding and would not provide adequate infomation regarding R.R’s condition. Moreover, Respondent initially failed to state why transport to the hospital was necessary. Additionally, Respondent failed to provide paramedics with R.R.’s medical records from The Baby Place…

xi. R.R. gave birth shortly after arriving at St. Luke’s Boise Medical Center. The infant was pronounced dead at approximately 3:03 a.m. on June 30, 2011.

xii. During the labor and delivery process, Respondent failed to keep complete and accurate records…

xiii. Approximately one year after R.R.’s pregnancy, Respondent asked another midwife to “re-do” R.R.’s labor charts. In or around June 2011, Respondent retrospectively created one page of chart notes from R.R.’s labor.

xiv. Respondent later stated that R.R. was uncooperative during labor and would not allow her to adequately monitor the fetal heart rates.

Both midwives have had their licenses suspended. They deserve far worse. There is not a single mitigating factor in any of these 3 deaths. All three involved gross malpractice as well interfering with transport and lying by the midwives.

These women should be in jail. But, in the world of homebirth advocacy, a pile of dead bodies is nothing more than an inconvenience. Predictably, homebirth advocates are rallying in support of these midwives:

Last night in the rain, about 30 parents of those children staged a rally of support here at KTVB studios. Many said they saw the report and felt compelled to share their positive experiences with The Baby Place.

Tracy Ryan told KTVB she came to the rally to speak for both women currently under investigation.

“This is a stand of support — a stand of support for two midwives in our community who have served these families, and now we are standing to serve them,” Ryan said.

I suppose that it’s fitting though: ignorant, immoral midwives supported by ignorant, immoral followers. That’s the world of homebirth advocacy.

From a letter sent to me by Mindy Wolfe, CPM. I found her commentary to be so powerful that I asked permission to reprint it:

In full disclosure, I was trained in the United States at a “college” of midwifery and then did nearly all of my clinical hours at a maternity clinic in the third world. I was not certified through the PEP process, but instead went from high school to a five month intensive course on basic health care and maternity care (everything from how to remove a tape worm to setting broken bones to suturing to resolving shoulder dystocia to manual removal of placentas to breastfeeding problems) and then spent one year at a charity maternity center in Davao City, Philippines. I then came back to the US and passed the NARM exam and the licensing exam in New Mexico.

Shortly after graduation, I moved back to Indiana, where CPMs are not licensed and midwifery is practicing medicine without a license and a felony. If for no other reason than that I have a young family, (although there are other reasons I’ll outline) the idea of being charged with a felony was enough such that I have never practiced in Indiana. I did, however, have opportunity to meet other women here in Indiana who do practice without a license. These encounters have opened my eyes to how poorly educated, dangerous and deceived most nearly everyone in the homebirth community truly is.

Some examples to further illustrate:

“What would you do in case of postpartum hemorrhage?”
“First, I would make sure the baby was breastfeeding well, then I would ask you to stop bleeding”

“You have a heart murmur and a strange heartbeat, but that’s not uncommon during pregnancy. You should be fine.”

“I prefer to use leeches for postpartum infections, I feel it’s a more natural approach”

“Twins that share the same placenta and same sac are just a variation of normal. It’s just that there are two babies”

I could go on but don’t suppose it’s necessary. For whatever underlying psychological reasons, these women are extremely dangerous practitioners who should be locked away. But, they continue on their sparkly path of destruction and misinformation. I wish it was as easy to call the police about a homebirth midwife as it is to call about the local drug dealer. Both should be out of business, for the sake of the well being of the community.

I did, for a time, work as an assistant to a CNM who provides homebirth services in Central Indiana, but actually ended up leaving, in part, because I feel that she is a reckless health care provider who has a martyr’s complex. Commonly accepted, mainstream medicine is all about the conspiracy, and every one is out to get her.

My last birth with her, the patient lived more than three hours from my house, and I was called to attend her birth alone because the two CNMs who were in the practice at the time were attending a disaster of a birth of mono/mono twins that was previously undiagnosed (the CNM did not require an ultrasound, even though the woman was measuring incredibly large for dates). The CNM’s protocol stated that the patient would not be further than 15 minutes from the hospital, but this woman lived in a very rural area at least 30 minutes from the nearest hospital. I handled her birth without any knowledge of her history (I had never even seen the chart), no medications at all, and an “assistant” who was a former vet’s assistant who had never seen a human birth in person. By grace we did not deserve, the woman’s labor and delivery were largely unremarkable and without incident, but after that point, I could not in good conscience work for this particular CNM any more.

After processing what has become something of an internal moral conflict, I have come to the belief that, with our system as it is, in Indiana, homebirth is not a safe option for anyone. Even the legal options are not well supervised, and any illegal option is the equivalent of Russian Roulette at best. From what I have seen and experienced, I believe that most birthing parents who pursue homebirth think they are doing the best for their families, and most homebirth midwives simply are not educated enough to know what they do not know. It’s dangerous, dangerous business; and if I had an effective platform for disseminating that information, I’d happily put my name on it.

My education, although more extensive than the PEP process that so many midwives use, was insufficient to the task of being an independent health care provider, and that being the case, I do not and will not practice, even if licensure was an option in Indiana. For whatever it’s worth, I took the Hippocratic Oath, too, and hang my hat on “do no harm”. I have come to accept that an extension of my promise to “do no harm” is to not remain silent.

It is axiomatic in homebirth circles that the Netherlands, the country with the highest rate of homebirth in the industrialized world, is a shining example of the safety and benefits of homebirth.

But it’s not and it hasn’t been for a number of years.

In the article Trouble in paradise, Hans Pols, senior lecturer in History and Philosophy of Science, University of Sydney, and a specialist in the study of Dutch birth practices, explains what happened:

It all started in 2003, when a major European study showed that perinatal mortality rates in the Netherlands were among the highest in Europe (10.5 per 1000 births …). After initial disbelief, denial … and criticism of the study’s methodology .., it was concluded that ‘the Netherlands has a problem’…

This startling realization prompted the government to sponsor a number of studies investigating the problem:

In the second quarter of 2010, the results of a large research project commissioned by the Ministry of Health were published. It concluded that the chances of an adverse outcome increase dramatically for women who were transferred to a hospital during delivery. In addition, the researchers noted that 25 per cent of risk factors had not been recognised by midwives, who are responsible for screening for them. Deficiencies in the organisation of care were thought to be responsible: in particular, the lack of communication, coordination and cooperation between midwives and obstetricians.

And:

Later that year, a study [Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: prospective cohort study] claimed that babies of women classified as low risk and starting care under the supervision of a midwife, had a higher rate of perinatal death and the same rate of admission to a neonatal intensive care unit when compared to babies of high risk women starting labour under the care of obstetricians. When a woman was transferred from home to the hospital during her delivery, perimortality rates increased almost fourfold…

Ironically, while American homebirth advocates have been (wrongly) touting the Netherlands as a homebirth paradise, Dutch women have reacted to the revelations that midwife care has a higher rate of perinatal death.

Giving birth at home appears to be falling out of favour in the Netherlands. The number of women opting for hospital births is increasing (from 70 per cent ten years ago to 75 per cent today), even though women classified as low-risk are required to pay additional fees…

And it is not just the issue of safety that is propelling them into hospitals:

The main reason is the extensive negative publicity related to homebirth and the availability of pain relief in hospitals. For a long time, both midwives and physicians discouraged pharmaceutical pain relief during labour. Dutch feminists have called for the right of women to pain relief, in particular epidurals, and questioned ‘the ideology of natural delivery and the positive meaning attached by midwives to women’s capacity to deal with pain without pharmacological support.’ Following a 2008 ministerial directive, women should receive pain relief on request …

Pols concludes:

… In the Netherlands, giving birth at home increasingly appears as an archaic procedure, once supported by an overly idealistic belief in the benign powers of nature. Although a great number of recommendations has been made and many plans developed, the amount of actual change thus far is disappointing. The Netherlands is the homebirth paradise no more and few international delegations will be visiting the Low Countries to see how delivery care is organised there.

Meet Abel, a gorgeous toddler who cannot walk, talk or sit unaided as a result of oxygen deprivation sustained at a birth supervised by homebirth midwives.

Abel’s parents believe that the midwives and the birth center at which they worked should be held accountable.

According to the Bend Bulletin

… Kristine and Greg Andrews — on behalf of their son — are suing the state of Oregon, Motherwise Community Birth Center, midwife Nicole Tucker, CPM and midwife Christyn King, CPM for the medical problems they say the baby faces as a result of oxygen starvation during birth.

The lawsuit asks for $25 million in noneconomic damages as well as $22.5 million in economic damages in the form of ongoing medical and therapeutic care and lost wages. It also asks for $3 million in noneconomic damages to Kristine Andrews for the experience she had with her son’s birth…

The lawsuit states no monitoring equipment was used to check the fetal heart rate. Nevertheless, “the fetal heart rate was noted to indicate periodic bradycardia (slow heart rate) and nonreassuring decelerations of the fetal heart rate.”

When born, the infant did not respond to stimulation and did not breathe on his own. He was taken to St. Charles Bend, and 10 days later was discharged with signs of brain damage caused by oxygen starvation from birth.

The baby suffered, among other things, significant brain damage and cerebral palsy.

Abel’s parents have not stopped there:

Finally, the lawsuit alleges the state was negligent.

The Oregon Administrative Rules have a list of “absolute risk factors” for birthing centers. When a risk factor is present, the regulations state a pregnant mother should be transferred to a higher level of care, like a hospital. One of the risk factors is hypertension. The state listed the threshold at a blood pressure of 150/100.

According to the lawsuit, that threshold was “inappropriate and not evidence based.”

The Andrewses allege the state was negligent for several reasons, most notably because of the blood pressure level it lists as a risk factor. The lawsuit also alleges the state didn’t require a mandatory disclosure form … and that it didn’t implement “evidence based standards for the protection of Oregon citizens.”

In my view, this lawsuit, and a similar suit filed in Michigan are just the first shots across the bow. I suspect that, ironically, the ongoing attempt to popularize homebirth and license homebirth midwives is going to end in the abolition of the homebirth midwifery credential, the CPM (certified professional midwife) and reverse the trend to license homebirth midwives.

Before Ricki Lake and The Business of Being Born, and before the Big Push, the national effort to license homebirth midwives, homebirth was a practice restricted to true believers. Sure homebirth dramatically increased the risk of perinatal death, but lawsuits rarely followed in the wake of those deaths. For the true believers, process is more important than outcome, and a few dead babies here or there did not weaken their commitment to privileging the process.

But homebirth midwives got greedy. They wanted access to insurance reimbursement and to more customers. The resulting effort to popularize homebirth has led to women choosing homebirth because they believed the propaganda. They thought homebirth was safe because that’s what homebirth advocacy organization claim, despite their own data that shows that homebirth increases the risk of neonatal death. Indeed, the Midwives Alliance of North America (MANA), the organization that represents homebirth midwives, refuses to release their own death rates.

Parents learned in the hardest way possible about the dangers of homebirth and that homebirth midwives are not honest about the real risks of childbirth, about the fact that the CPM is not accepted by any other country in the first world due to lack of education and training, and that being near a hospital is meaningless in the face of a life threatening emergency.

This new group of homebirth parents were never true believers and they see no reason to protect incompetent midwives and deceitful homebirth advocacy organizations. They intend to hold them accountable.

And that will hopefully mark the beginning of the end for the licensing of homebirth midwives.

Learn more about Abel and the foundation his family set up to support children with cerebral palsy and birth trauma at We Are Abel.

I read this paragraph last night and have been thinking about it ever since.

[They]have built an alternative world of internal legitimacy that mimics all the features of the mainstream research world — the journals, the conferences, the publications, the letters after the names — and some leaders have gained access to policy-making positions. Mixing an environmentally inflected critique of [obstetrics] and Big Pharma with a libertarian individualist account of health has been a resonant formulation for some years now, with support flowing in from both the Left and the Right.

This is a description of vaccine rejectionists, but it applies equally well to natural childbirth and homebirth advocates.

The paragraph appears in the paper The Legitimacy of Vaccine Critics: What Is Left after the Autism Hypothesis? by Anna Kirkland, published in Journal of Health Politics, Policy and Law in October 2011.

In both cases, vaccine rejection and NCB and homebirth advocacy, the paragraph provides a succinct explanation for how and why a movement based on pseudoscience has gained a hold on its followers and why those followers appear impervious to the massive amount of scientific evidence arrayed against their claims. What really resonated for me was the description of the alternate world, for it often seems that NCB and homebirth advocates do inhabit an alternate world that has nothing to do with obstetrics, science or statistics.

As I have written countless times, most of what homebirth advocates think they “know” is factually false, yet they don’t realize it. That’s because their alternate world mimics all the features of the mainstream scientific world.

Consider:

• Journals: The premier journal of the NCB and homebirth communities is Birth, published on behalf of Lamaze International. Although it is technically a peer review journal, it is made up in large part of papers written by editorial board, which includes such luminaries of the NCB and homebirth movements as Eugene Declercq, Marc J.N.C. Keirse, Michael Klein, and Marian F. MacDorman. Birth is where you send your paper if you can’t get it published in a real medical journal, and it carries little influence in the world of obstetrics, as its impact factor of 1.82 attests. For comparison, the impact factor of Obstetrics and Gynecology is 4.39.

  There is also a plethora of non-peer review journals including The Journal of Perinatal Education, another Lamaze production, and Midwifery Today, one of the many facets of the Ina May Gaskin empire.

• Conferences: NCB and homebirth advocates love conferences, ranging from meetings of professional organizations like the Midwives Alliance of North America, through single purpose conferences like The Homebirth Consensus Summit, to festivals of ignorance like the Trust Birth Conference. Unlike traditional scientific conferences where all viewpoints are heard on vigorous disagreements aired, NCB and homebirth conferences are heavily censored to remove dissenting views with the express purpose of creating an echo chamber for non-scientific claims.
• Letters after names: NCB and homebirth advocates try to confer legitimacy on themselves by adding letters after their names. The CPM (certified professional midwife) “credential” is the premier example of a made up designation meant to impress the faithful and to fool outsiders, but there are countless other combinations including LCCE – Lamaze Certified Childbirth Educator, CD(DONA)- certified doula (Doulas of North America), and my personal favorite, CHBE – Certified Happiest Baby Educators.
• Libertarian individualist account of health: Homebirth advocates like to invoke all sorts of made up rights, like the “birth as a human right,” and the “right” to be attended by the provider of one’s choice. Homebirth advocates decry government interference in birth choices, yet, ironically, spend a great deal of time lobbying for government involvement in paying for favored birth choices and providers.

As Kirkland explains about vaccine rejectionists:

[They] share an internally bounded world in which both individuals and ideas enjoy legitimacy, but undercut the groups’ external legitimacy … (emphasis in original)

NCB and homebirth advocates are shocked that their assertions about childbirth are greeted with disbelief and even contempt by mainstream medical practitioners. Their predilection for conspiracy theories leads them to envision a massive conspiracy among doctors and hospitals, and it simply never occurs to them that they exist in an echo chamber which mirrors their own nonsensical claims back to them.

Kirkland asks a question about vaccine rejectionists that can also be asked about NCB and homebirth advocates:

Under what conditions could we imagine leaders reporting back at a later conference that the right study had finally been done and proved them wrong?

When will we see Ina May Gaskin acknowledge that homebirth increases the risk of perinatal death?

When will we hear the leaders of Lamaze International acknowledge that the Fear-Tension-Pain cycle was made up Grantly Dick-Read and has little to no basis in science?

When will Marsden Wagner publicly acknowledge that there does not exist, nor did there ever exist, scientific data to support his assertion of an optimal C-section rate of 10-15%?

The answer to all three, of course, is never.

NCB and homebirth advocates occupy an alternate world of internal legitimacy, which means never having to face dissent, never having to respond to real scientific evidence, and never having to acknowledge that most of what they promote is factually false.

How pathetically inadequate is the homebirth midwifery CPM “credential”?

Requiring a high school degree or (its equivalent) constitutes “tightening.”

The CPM (certified professional midwife)is the pretend “credential” fabricated by Ina May Gaskin and colleagues, and awarded to themselves. Its purpose is to trick lay people and legislators into believing homebirth midwives are trained. It is not recognized by any other first world country because it does not meet even minimal education and training requirements in the UK, the Netherlands, Australia, Canada or anywhere else.

In keeping with its purpose of awarding a “credential” to anyone who wants one, the Midwives Alliance of North America (MANA), the organization started by Gaskin and colleagues, refused to create formal educational requirements. Or as euphemistically explained, MANA:

embraces multiple educational routes of entry into the profession of midwifery including institutionally-based programs, university-based programs, at-a-distance learning, and apprenticeship

As Professor Katherine Beckett acknowledged:

… Many in the midwifery community have been concerned that the extensive educational requirements associated with professionalization will exclude midwives already trained through apprenticeship, as well as aspiring midwives who are unable to relocate and/or pay for a formal education. In order to include such women, MANA acknowledges ‘‘multiple routes of entry’’ to the profession and allows applicants for the CPM degree to acquire their knowledge and skills through either formal education or apprenticeship; a woman whose education ends with high school can therefore be certified as a CPM. In public and political forums such as state capitol buildings, most midwives do not stress that they may be certified without extensive formal education …

But now, in an effort to bring rigor unseen heretofore to the CPM credentialing process, the North American Registry of Midwives (NARM), the sister organization of MANA, has declared:

All applicants will be required to submit evidence of a high school diploma or equivalent.

That’s right. In an age in which 92.7% of American women graduate from high school, homebirth midwives have taken the unprecedented step of instituting the requirement for a degree that everyone already has.

Why the change? There are two possible explanations that I can think of.

First, it may have finally occurred to MANA that awarding credentials to women who don’t even have high school diplomas has the potential to undermine the legitimacy of the CPM in the eyes of the general public.

Second, they may have been required to do so by the National Commission on Certifying Agencies (NCCA).

Homebirth midwives like to boast that the CPM is accredited by the NCCA. The NCCA accredits:

… a variety of certification programs/organizations that assess professional competence. Certification programs that receive NCCA Accreditation demonstrate compliance with the NCCA’s Standards for the Accreditation of Certification Programs…

NCCA accredited programs certify individuals in a wide range of professions and occupations including nurses, automotive professionals, respiratory therapists, counselors, emergency technicians, crane operators and more.

The NCCA does NOT evaluate the validity of the certification, whether that is the CPM or a license to operate a crane. It merely evaluates the credentialing process to ensure that it is impartial, properly administered, and includes relevant requirements. I would not be surprised if NARM’s Portfolio Education Process (PEP) ran afoul of Standard 8 of the NCCA Standards for the Accreditation of Certification Programs:

Once a program is accredited, “grandfathering,” or any other procedure for granting a credential in the absence of evaluating the knowledge and/or skill of an individual, is not acceptable…

Grandfathering is generally seen as a conflict with stakeholder interests. It is used from time to time in licensure as a means of protecting the rights of individuals who entered a profession prior to its regulation and should not be excluded from the right to practice…

One of the fundamental purposes of the PEP is to grandfather in self proclaimed midwives who practice without ever completing the basic certification requirements. Indeed, in 2000, when Johnson and Daviss conducted their famous study, more than 90% of the CPMs in the study had obtained the CPM through PEP. That might have been reasonable then since the requirements for certification had been codified only in 1994. But now, more than a decade later, as many as 2/3 of CPMs obtain the credential through PEP. According to the NCCA, that is unacceptable.

In other words, NARM may have been forced to institute the requirement for a high school diploma (or its equivalent) or risk losing the accreditation of its credentialing process.

The CPM credential is a joke perpetrated on unsuspecting lay people and legislators. The fact that a high school diploma represents a “tightening” of the requirements makes that quite clear.

First child: Trusting birth

The mother is a homebirth midwife who decided to have an unassisted homebirth.

Alternate video link here.

Trust led to:

Second child: Fearing birth

Fear led to:

The take home message is pretty stark:

Trusting birth (ignoring post dates, protracted labor, homebirth, lack of a trained attendant) = Death.

Fearing birth (hospital birth, multiple trained attendants, postdates induction, IV, etc) = Joy.

Would you boast about dangling your baby over the edge of a balcony to please your fans?

It’s really no different from what homebirth advocates do when they boast about a breech homebirth to impress their peers. Oh, wait; it is a bit different. A breech homebirth is far more dangerous than dangling your baby off a balcony.

Yesterday, the twitter feed on #homebirth was filled with worshipful retweets of a frank breech delivery at homebirth (“Graphic!”), breathlessly subtitled “A frank breech at home, against all odds.”

No less an authority than Gina Crossly-Corcoran, The Feminist Breeder, weighed in with:

This is one of the coolest things you’ll ever see. A graphic video of a frank breech homebirth …

Why was TFB praising this irresponsible, dangerous choice as cool? Perhaps she wanted to offer confirmation of what I wrote last week about Homebirth, immaturity and risk taking:

… [T]he more contraindications you have to homebirth, the more prestige you will get from having a homebirth…

In the case of homebirth advocates, it’s not that they are unaware of the risk. They do it and then publicize it specifically because they know about the risks but wish to preen within a subculture that admires taking a dare more than ensuring a safe outcome.

The next time you see a blog post, tweet, or homebirth video boasting about twins, or footling breech or premature birth at home, keep that in mind. These don’t demonstrate that the risk taking behavior is safe. They’re no different than boasting that you drove home drunk and stoned and made it there without killing yourself.

QED!

Why was the mother chortling that she defied the odds? I suspect the mother is referring the odds of having a breech vaginal delivery in the face of a massive amount of evidence that it is a dangerous, selfish, stupid choice. She defied those odds all right.

How about the odds that the baby might die or suffer a serious injury? She defied those odds, too, although considering the typical ignorance of homebirth advocates, she probably had no idea what they were.

According to this Medscape article on breech, discussing the outcome of the Hannah study:

The composite measurement of either perinatal mortality or serious neonatal morbidity by 6 weeks of life was significantly lower in the planned cesarean group than in the planned vaginal group (5% vs 1.6%, P < .0001). Six of 16 neonatal deaths were associated with difficult vaginal deliveries, and 4 deaths were associated with fetal heart rate abnormalities. The reduction in risk in the cesarean group was even greater in participating countries with overall low perinatal mortality rates as reported by the World Health Organization. The difference in perinatal outcome held after controlling for the experience level of the obstetrician.

And that’s in the hospital with every possible type of emergency assistance available.

How dangerous is breech homebirth?

Consider the verdict of Marc J. N. C. Keirse MD, DPhil, DPH, FRCOG, FRANZCOG, one of the leading exponents of breech vaginal birth and an editor of the journal Birth, the de facto journal of the natural childbirth movement. Dr. Kierse shared this view in a commentary bemoaning the impact of the Hannah breech trial (which found that breech increases the risk of neonatal death) in promoting C-section for the delivery of breech babies.

Home birth is a well-established recipe for disaster for a baby in breech presentation and contrary to any sensible guidelines that have ever been developed.

It’s hard to get more definitive than that.

All in all, it’s an object lesson in the ignorance, narcissism and immaturity of homebirth advocates. Michael Jackson did something incredibly stupid when he dangled his baby over a balcony, but, in reality, the odds that he would injure or kill the baby were very low. This mother did something far more stupid in attempting a breech homebirth; the odds that the baby would be permanently injured or die were high.

At least Michael Jackson did not boast about his stupidity, but then again, he probably didn’t care whether The Feminist Breeder and her ilk thought that risking a baby’s life is “cool.”