Here’s an interesting thought:

… women’s reports of “lower childbirth satisfaction” after cesarean should not be attributed to excessive and appropriative medical intervention. Rather, their negative evaluation of their birthing experience is produced by a cultural discourse of “natural” childbirth that encourages them to measure their labors against an inherently moralistic and ultimately pernicious ideal of birth.

In other words, the philosophy of natural childbirth, far from empowering women, is destructive to women’s self esteem.

This is the central insight of the feminist critique of natural childbirth known as the “critique of the idealized birth.” As Jane Clare Jones explains in Idealized and Industrialized Labor: Anatomy of a Feminist Controversy, published last fall in the feminist journal Hypatia:

… [T]he idealization critique is … concerned with the alternative birth movement’s role in prescribing coercive norms that generate inflated expectations about the degree of control women can and should exercise over the process. Indeed, as Lobel and DeLuca note, one possible way to reduce the adverse effects of cesareans on mothers’ reports of “childbirth satisfaction” would be to encourage them to “develop realistic expectations” about labor, rather than educating them to resist obstetric practice—as has been the main strategy of the natural childbirth movement.

The leading exponent of the critique of idealized labor is Georgetown University philosophy professor Rebecca Kukla:

For Kukla, the alternative birth movement’s encouragement of such strategies as childbirth classes and birth plans, while originally laudable in intent, is responsible for establishing “completely unrealistic expectations concerning how much control one can possibly have over the laboring process.” As a consequence, the movement is implicated in “setting women up for feelings of failure, lack of confidence, disappointment, and maternal inadequacy when things do not go according to plan, even when mother and baby end up healthy”. Thus, critics like Kukla suggest, while the natural childbirth movement styles itself as concerned with empowering laboring women, its establishment of a normative ideal of birth is, ultimately, disciplinary and punitive. (my emphasis)

As I have written repeatedly, there are two critical problems with natural childbirth. First, it is based on a purported past that never existed. In fact, the past to which the natural childbirth literature refers is nothing more than a cultural construct:

… [The] alternative birthing literature constantly appeals to “the authority of nature,” conceived on the basis of “an emphatically ahistorical and anticultural notion of time.” Such invocations of timeless female physiology function … to posit a body that exists prior to or outside culture and that, moreover, conceals the fact that the “rhetorical recourse to the natural body” is “itself cultural” (Michie and Cahn 1996, 49). Thus, the alternative birthing movement is guilty … of grounding its normative ideals on a notion of “nature” that is rhetorically and culturally constituted…

Second, it a form of biological essentialism:

… [T]he idealization of nature is implicated in propagating an essentialist notion of femininity, one that allies “the female” to a host of traditionally devalued cultural categories. While second-wave “matriarchal” or “cultural” feminists undertook a celebratory re-appropriation of the equation of woman to nature, many feminists of the third wave remain leery of the emancipatory potential of re-inscribing binary polarities that have long served to discipline women’s bodies and behaviors…

This is not surprising considering that the two founders of modern natural childbirth philosophy were both profoundly sexist.

I have written extensively about Grantly Dick-Read who fabricated the philosophy of natural childbirth to aid in the eugenics battle against “race suicide” and drew upon widely prevalent racist notions of hypersexualized black women who reproduced easily and “hysterical” white women whose ovaries supposed shriveled as they acquired education and political rights.

In this paper, though, I learned about the sexism of Fernand Lamaze. According to natural childbirth advocates Sheila Kitzinger:

… [T]he disciplinary nature of Lamaze’s approach to childbirth is evident from Sheila Kitzinger’s description of the methods he deployed while working in a Paris clinic during the 1950s. According to Kitzinger, Lamaze consistently ranked the women’s performance in childbirth from “excellent” to “complete failure” on the basis of their “restlessness and screams.” Those who “failed” were, he thought, “themselves responsible because they harbored doubts or had not practiced sufficiently,” and, rather predictably, “intellectual” women who “asked too many questions” were considered by Lamaze to be the most “certain to fail”

The bottom line is that natural childbirth philosophy does not empower women. It subjugates them by “supervaluing the denigrated categories with which women have long been associated.”

The idealization of “natural” birth functions ideologically to impose a prescriptive normativity on women’s childbearing in a manner that deprives them of agency, inflates their expectations, and opens them to social stigmatization and a profound sense of shame if they fail to enact the ideal.

In other words, the philosophy of natural childbirth is just another way to accuse women of being failures.

It is perhaps the most powerful claim in the NCB and homebirth advocacy armamentarium. It’s the claim that the US ranks poorly on infant mortality. It’s powerful, it’s shocking and it’s completely false.

I written about this repeatedly over the years. First, infant mortality (death from birth to one year of age) is a measure of pediatric care, not obstetric care. Neonatal mortality (death from birth to 28 days of age) is more accurate, and perinatal mortality (late stillbirths + neonatal deaths) is the most accurate measure of obstetric care. Second, many countries cheat in calculating both infant and neonatal deaths.

How do they cheat? According to the World Health Organization, the infant death rate is the number of infant deaths divided by the total number of live births in a year. Similarly, the WHO definition of neonatal mortality is the number of neonatal deaths divided by the total number of live births in a year. Not surprisingly ALL live born babies, regardless of weight or gestational age are supposed to be included in these calculations. The US adheres to these guidelines, as does Canada. Most other first world countries do not. They cheat by deliberately excluding very premature babies. In other words, they classify the babies who are most likely to die as born dead (and therefore not included) even when they are born alive.

So, for example, a 28 weeker who lives for several days is counted in the US or Canadian neonatal mortality statistics, but is treated in many other countries as if it never existed, thereby artificially lowering the neonatal mortality rate.

This has a huge impact on mortality rates. That’s why other countries cheat in the first place. A paper published last month in the British Medical Journal has quantified exactly how large the impact is. It turns out that the US (and Canada) don’t have poor rankings and never had poor rankings. They actually have among the best ranking for infant and neonatal mortality it the world!

The paper is Influence of definition based versus pragmatic birth registration on international comparisons of perinatal and infant mortality: population based retrospective study, written by multiple scientists at Fetal and Infant Health Study Group of the Canadian Perinatal Surveillance System.

The authors investigated the cheating by determining how many premature babies were included in the mortality rates. They found that most countries besides the US and Canada exclude live born babies less than 500 gm (1 pound, the typical weight at 22-23 weeks gestation and at the outer limit of viability). More surprising, many countries exclude live babies less than 1,000 gm (2 pounds, the typical weight at 28 weeks gestation, and known to have a very high survival rate).

Here is what they found:

Results: The proportion of live births under 500 g varied widely from less than 1 per 10 000 live births in Belgium and Ireland to 10.8 per 10 000 live births in Canada and 16.9 in the United States. Neonatal deaths under 500 g, as a proportion of all neonatal deaths, also ranged from less than 1% in countries such as Luxembourg and Malta to 29.6% in Canada and 31.1% in the United States. Rankings of countries based on crude fetal, neonatal, and infant mortality rates differed substantially from rankings based on rates calculated after exclusion of births with a birth weight of less than 1000 g or a gestational age of less than 28 weeks.

Conclusions: International differences in reported rates of extremely low birthweight and very early gestation births probably reflect variations in registration of births and compromise the validity of international rankings of perinatal and infant mortality.

The following table shows the crude mortality rate for each country (the rate that the country uses) and compares it to the corrected mortality rate. The corrected mortality rate is the neonatal mortality for live born babies of 1,000 gm or more (click on it for a larger view).

Crude neonatal mortality rates are on the left side of the table. As you can see, the US ranks 22nd, behind countries like Malta and Hungary. However, when the crude results are adjusted by removing all babies under 1000 gm (which weren’t included in the crude rates for most countries), the results are very different. Almost all the countries in the table have a neonatal mortality rate just about the same as the US, or even higher.

The graph below illustrates the results (click on it for a larger view).

The top line represents crude neonatal mortality rates ranked in rising order. The bottom line represents corrected rates. Now instead of the US having the highest rate of neonatal mortality, it has one of the lowest rates.

How do countries that exclude live born premature infants from mortality rates account for those babies? They categorize them as stillbirths. That’s why perinatal mortality (neonatal mortality + stillbirths) is the most accurate measure of obstetric care. Perinatal mortality does not allow countries to hide premature babies as if they never existed.

The conclusion is clear. International comparisons of crude infant or neonatal mortality rates are invalid. They are grossly inaccurate because many countries cheat in order to make their statistics look better.

The authors note:

The World Health Organization … has long defined a live birth as any product of conception that shows signs of life at birth, with no consideration for birthweight or gestational age criteria. Although this definition remains unchallenged, countries have widely varying regulations for registration of birth that range from definition based to pragmatic. For instance, birth registration is required for all live births that satisfy the WHO’s definition of live birth in Canada, England and Wales, and the United States, whereas countries such as the Czech Republic, France, and the Netherlands specify limits based on some combination of gestational age (for example, at least 22 weeks), birth weight (for example, at least 500 g), or survival (for example, any live birth irrespective of birth weight that survives the first 24 hours after birth). Procedural differences due to longstanding traditions, social attitudes, and local incentives (including financial remuneration of healthcare providers) also probably dictate whether an infant at the borderline of viability is registered…

In summary, we observed large international differences in the reported proportion of live births under 500 g and under 1000 g birth weight and in neonatal deaths in these birthweight categories. International comparisons based on crude fetal, neonatal, and infant mortality rates yielded results that differed from comparisons that excluded extremely low birthweight and early gestation births, especially those at the borderline of viability. Variations in the registration of births at the borderline of viability and related problems compromise the validity of international rankings of industrialised countries by perinatal and infant mortality.

The bottom line is that the US does not now and has not in the past ranked poorly on infant and neonatal mortality. The US has one of the lowest rates in the world and NCB and homebirth advocates should stop lying about it in their efforts to make homebirth look “safe.”

On its website, Midwifery Today features a timeline entitle The History of Midwifery and Childbirth In America. The timeline extends from 1660 to the late 1990’s. It contains interesting tidbits of information about childbirth practices, interspersed with general historical events. It seems quite comprehensive with the exception of one curious omission. It barely mentions mortality statistcs.

To my mind, the history of childbirth is a continuing effort to master its inherent dangers. Childbirth is and has always been, in every time, place and culture, one of the leading causes of death of young women and the leading cause of death of newborns. Indeed, the primary purpose of a childbirth attendant is to increase the chance that the mother will live, at least, and hopefully the baby will live too.

The secondary purpose of a childbirth attendant is to comfort the mother as she endures the excruciating pain of labor. The history of childbirth has also been a continuing effort to master the pain of childbirth. That’s another curious omission from the Midwifery Timeline. It makes no mention of chloroform, general anesthesia or epidurals, arguably among the most important advances in the history of childbirth.

I suspect that the reason for these glaring omissions reflects the direct entry midwifery obsession with process. The outcome, whether or not the mother or baby lived, is virtually irrelevant.

Perhaps another reason why the timeline is silent on the issue of mortality statistics is that they illustrate the spectacular success of modern American obstetrics. For hundreds of years midwives presided over childbirth and had almost no impact on the appalling rates of maternal and neonatal mortality. It was only with the advent of modern obstetrics that the mortality rates began to fall.

I thought it might be interesting to look at the statistics that the Midwifery Today timeline left out. I took as the starting point the timeline itself. It faithfully chronicles the movement of birth from the home to the hospital starting in 1900. In every decade, it reports the ever increasing percentage of hospital births. Yet it is silent on massive declines in maternal and infant mortality that occurred simultaneously. For each point in the timeline where the percentage of hospital deliveries is mentioned, I looked up the corresponding maternal and neonatal mortality rates. This graph is the result.

As the percentage of births in the hospital rose, the maternal and neonatal mortality plunged. The graph is a powerful way of demonstrating that the association is dramatic. During the 1900’s, for the first time in history, using the tools of modern obstetrics, the terrible inherent dangers of childbirth were mastered. Could we do even better? No doubt, and the search continues to make birth even safer than it is today. As Dr. Atul Gawande wrote in his New Yorker article (The Score, How childbirth went industrial), “Nothing else in medicine has saved lives on the scale that obstetrics has.” The graph makes that very clear indeed.

Infant and maternal mortality rates abstracted from CDC on Infant and Maternal Mortality in the United States: 1900-1999. Although neonatal mortality is a much better measure of obstetric practice, neonatal mortality figures were not collected in the earlier part of the century. Therefore, infant mortality statistics are used as a proxy, albeit imperfect.

This piece first appeared in December 2009.

Consider the following situations:

1. Homebirth advocate Rixa Freeze proudly relates the near death of her baby at an (oops!) unassisted homebirth:

Soon after the birth, Inga lost muscle tone and color. I quickly realized that I needed to perform mouth-to-mouth. Fortunately, I became certified in neonatal resuscitation several years ago, so I knew what to do. It was tricky getting the angle right, since the cord was short. I gave her five breaths. After each breath, she coughed and perked up a bit more.

Rixa herself was spinning the near disaster as though it was nothing serious and that she had educated herself to handle the situation calmly and with ease. Rixa seems to imply that what happened to Inga is the worst emergency that can happen at homebirth and all you have to do is take a neonatal resuscitation course and you will be adequately prepared to save your baby’s life.

2. The mother of baby Florence, discussed in yesterday’s post (What were they thinking?) whose baby is in the NICU due to the irresponsible actions of the patient and her midwives. The mother is obsessed with the issue of whether the baby is getting breast milk and has completely ignored the more pressing issues of the baby’s survival and brain function.

3. A pathetically ignorant homebirth blogger currently treating us to the series The safety of home birth and why I chose it twice :

I’m not going to pretend that my first birth was all roses. My first baby was born with a low Apgar score. She wasn’t breathing because the cord was wrapped around her neck (which happens in 25% of births), and it took my experienced midwife several minutes of CPR to get her breathing. But I wasn’t frantic. Do you know why? Because the cord hadn’t been cut, and I knew that she was still getting the oxygen she needed. She would be fine because she was getting oxygen the same way she had for the previous 9 months. Now in a hospital, it’s pretty likely that cord would have been cut right away and my baby rushed away . Then I would have had cause to worry. Then my beautiful baby girl may have suffered brain damage from lack of oxygen.

These three homebirth advocates ended up in desperate situations because they suffer from “optimistic bias.” Optimistic bias also leads them to minimize the significance of major complications, and give outsize attention to small risks while ignoring large one.

What is optimistic bias? In an editorial in the August 2011 issue of the Journal of Clinical Nursing entitled The implications of the optimistic bias for nursing and health, Aja Murray explains the phenomenon.

The tendency to believe that negative events are less likely and positive events more likely to happen to oneself than to others is known as the optimistic bias. In a health setting, this can manifest as a serious underestimation of health risk. Biases can be highly resistant to change and this can contribute to an unwillingness to take preventative or restorative action…

That describes homebirth advocates perfectly. They grossly underestimate the risk of pregnancy complications and therefore they reflexively refuse to take any preventive action (prenatal tests, antibiotics for group B strep, C-section for breech, etc.) and even when complications do occur, as they inevitably occur in exact same proportions as the rest of the population, they delay and even refuse lifesaving and neonatal brain sparing treatment. And when bad outcomes occur, they dismiss their significance as minor.

Homebirth advocates don’t merely fall prey to optimistic bias, they actively promote it among themselves and proselytize optimistic bias to everyone else. They justify this optimistic bias by claiming that they aren’t going to develop pregnancy complications because they practice “good nutrition,” they exercise and they employ bizarre alternative treatments like “cranio-sacral therapy,” even though there is precisely zero evidence that these have any impact on the development and severity of pregnancy complications.

But optimistic bias is not a virtue, it is a danger. As Murray explains:

Optimistically biased judgements can cause individuals to underestimate their vulnerability to a wide range of health conditions, including cancer, cardiac, substance abuse and HIV. It is also associated with greater risk of health-related factors such as high cholesterol.

… Overall, however, the evidence suggests that having an optimistic bias is more likely to have a net negative impact on health.

That is certainly the case for homebirth advocates. The only people who appear to be unaware of the fact that homebirth increases the risk of perinatal death are homebirth advocates.

Why do they engage in optimistic bias?

Evidence suggests that both motivational factors, which serve to preserve self-esteem and avoid anxiety, and non-motivational factors, such as errors in comparative judgements, interact to produce and maintain an optimistic bias . Thus, any intervention must target both. Most interventions to date have, however, focused on non-motivational aspects of optimistic biases. … [Attempts] to reduce participant reliance on inaccurate information by providing information about their relevant risk factors and highlighting aspects of the information that would be expected to produce unfavourable comparative judgements. These interventions, however, failed to produce a consistent reduction in bias…

… [O]ptimistic bias … encourages attitudes and behaviour which minimise awareness of undesirable and anxiety-provoking information which may threaten a positive self-image… [I]ndividuals who express an optimistic bias are less likely to be aware of risks to their health, less open to novel health-relevant information and more susceptible to believing health myths. Indeed a significant predictor of an individual’s health relevant behaviour is his/her feelings about health risk which can outweigh a rational evaluation of risk.

Does this apply to homebirth advocates?

✓ Preservation of self esteem
✓ Avoiding anxiety
✓ Errors in comparative judgment
✓ Resistance to scientific evidence
✓ Belief in health myths

It most certainly does!

Moreover:

If the [health risk] is perceived to be positive and controllable, then individuals are likely to be more biased in their comparative judgments than if the dimension is positive but uncontrollable. This implies that patients affected by health problems that are amenable to protective behaviour, such as taking regular exercise, are most likely to underestimate their health risk. Ironically, those for whom there is the most scope for health improvement are likely to be the least motivated to take steps to make these improvements.

Homebirth advocates insist that they can control their risk of pregnancy complications. Therefore, they dramatically underestimate those risks and refuse to take the steps most likely to reduce the risks, including conventional antepartum care, prenatal tests, and most importantly, delivery in a hospital.

Murray sees a role for health providers in reducing optimistic bias. Unfortunately, in homebirth advocacy, the providers (midwives) suffer as much or more from the same optimistic bias, and for the same reasons. Homebirth midwifery is basically a hobby designed to boost the self-esteem of poorly educated homebirth midwives. They are resistant to scientific evidence since they have little idea what the scientific evidence shows, they are incapable of making comparative judgments of risk and they believe in health myths.

Optimistic bias is notoriously resistant to evidence since it is not about evidence; it is about the self-esteem of those who ignore health risks. That is certainly the case in homebirth advocacy. Of course health care providers should continue to explain the health risks, but they might consider going a step further and addressing the underlying issue. A frank discussion of the way that all people, not just homebirth advocates, have a tendency to fool themselves about risk will shift the focus away from their purported “knowledge” to their motivations.

Just like smokers minimize the risk of lung cancer to themselves, and alcoholic minimize the impact of alcohol abuse on their health, homebirth advocates minimize the risk of pregnancy complications, both the risk that they will occur and the consequences of those complications. In all three cases it is not because the smokers, alcoholics or homebirth advocates are more “educated.” It’s just that they are better at kidding themselves.

I’ve written repeatedly about the scandalously poor care provided by many UK midwives in hospitals. Here’s an example of malpractice at home.

UK midwives apparently have no monopoly on stupidity. The mother, Julie received moronic advice on Facebook from a self-employed New Zealand midwife.

From a VBAC activist Facebook page (I have corrected the spelling errors for ease in reading):

12/24/2011

I had a C-section with my first fully asleep as he was breech and big, then 5 yrs later gave birth in hospital – but was cut and stitched with no pain relief – agony, then had another C-Section 7 yrs later due to baby in distress, then had another C-section 9 yrs later due to pre-eclampsia in 2008 and I am due again in 8 weeks and planning a home birth with community midwives who are supporting my decision . The doctor at my surgery informed social services of my decision for the home birth and not to immunise saying I was putting my baby at risk, they wrote to me and said i was within my rights to choose what I wanted! The doctor who did this got my blood pressure up to its highest point in this pregnancy!!

We have no hospital in our town now, so it would be a while until i got to a hospital should an emergency arise, but I have read on line of many women who had a healing and pleasant birth experience, even after many C-sections, by having their baby at home. I am trusting God and believe thinking positive instead of all the negatives will help things go well…

3/1/2012

I am 43 and 41 weeks pregnant & going for a VBA3C at home. I am 3 cm dilated after a membrane sweep to try to bring things on today. My waters broke on the 19th Feb, due date was 23rd Feb. I have agreed to a membrane sweep every 3 days if I don’t get into regular contractions. I have had irregular contractions and backache since the 19th.

They also found a swab showed i have something called GBS but my husband and have looked it up and it seems that most women carry this – there is apparently a 10% chance of it being passed onto baby, and could be fatal or brain damage if so!

The solution is to have a IVF drip with antibiotics, but only when in established labour, which i am not. A Caesarian doesn’t clear it either (phew) and i cannot be induced and don’t want to either. So there is no solution as far as we can see? Any advice please?

3/3/2012

I am still waiting!!!! I am slowly losing faith that i will homebirth this baby 🙁

I am two weeks since my SROM and 1 week over my due date, with no signs of contractions getting closer or more intense, just intense backache at times and the odd intense contraction!!!
The swab I had with the GBS strep B came back as having grown, whatever that means, we don’t really understand it – so we are so unsure of what we should do next apart from wait!!!

3/4/2012
Self-employed midwife Michelle Goodhew

Obviously you are keeping a close eye on baby with your midwives Julie… There is quite a bit of information of GBS and a good Cochrane review written on the subject. BTW you can give antibiotics at any stage, oral in pregnancy is fine too. Or some use garlic cloves for a more natural approach. It is a very transient bacteria but can be detrimental to babies as you mentioned. Take care Julie… have you seen a homeopath, tried acupuncture etc to get labour going?

3/4/2012

Hi Michelle, we came in hospital in the night as i had meconium on my pad, our midwives met us there and sorted everything out that we desired – i.e. no sheet up in theatre so we could see baby arrive when they did, and for me to hold my husband whilst i had the spinal, then we had a BABY GIRL named FLORENCE ROSE. She isn’t breathing alone, and is in special care – we are trusting God for her full health.

Thank you for all your support, it has been so helpful.

3/5/2012

Florence is critical as she has not been able to breathe alone since birth, she has been sedated so as not to knock out her tubes, the medical people just keep telling us she is very poorly. I hope God chooses to keep her here on earth.

3/6/2012

She remains stable, but good news today – i got to change her nappy. She had a lumbar puncture today to see if she has meningitis, as she has an infection. She is sedated at the moment. I will try to update you further.

The test came back clear from meningitis although they said they are observing the sample for growth over the next few days. She is still sedated and not taken any of my colostrum yet, it’s all in the fridge.

No update yet today.

Pondering strange practices associated with childbirth, many people imagine that they are the product of third world cultures. While it is true that third world cultures have unusual and superstitious childbirth practices, the most bizarre and the most disgusting almost always come from first world countries. No one in the third world devised the spectacular lie that childbirth is “orgasmic;” and women in the third world did not make up the practice of waterbirth and pretend that delivering a baby into fecally contaminated water provides a good start in life. For the winner of wackiest (and most disgusting) childbirth practice ever, though, I’d nominate another stunt made up by first world women: lotus birth.

Lotus birth is the decision to leave the placenta attached to the baby for several days until it rots off. It is a bizarre practice with no medical benefit and considerable risk, particularly the risk of massive infection. I’m not making this up. According to Lotus Fertility.com (“Serving your Inner Midwife”):

The baby is born and remains attached to its cord while the placenta is birthed. The baby’s placenta-cord is kept in-situ with the baby, gently wrapped in cloth or kept in an uncovered bowl near the mother, and the cord is sometimes wrapped in silk ribbon up to the baby’s belly. The cord quickly dries and shrinks in diameter, similar to sinew, and detaches often by the 3rd Postpartum day (but up to a week in certain humid indoor air conditions) leaving a perfect navel.

How is this accomplished?

…[T]he placenta is placed in a special bowl or wrapped in a ceremonial cloth (it is helpful to rinse it first, and remove clots)… Sea salt is also applied generously on both sides to aid drying and minimize scent. This small pillow and its cord are easily kept with the baby, and some women even use the Lotus pillow as an elbow prop during nursing…

In other words, in order to minimize the smell of rotting, the placenta is salted like a piece of dried meat. And as a bonus, you can use the rotting placenta as an elbow prop!

Why would anyone engage in such a bizarre and potential dangerous practice? Here’s the ostensible reason:

The practice … [is] called “Lotus Birth”, connecting the esteem held in the east for the Lotus to the esteem held for the intact baby as a holy child … Ahimsa, (non-violence in action and thought within one’s self and towards others) … is from the writings and leadership by Gandhi … and Martin Luther King, Jr.’s civil rights inspired marches followed soon after. Approaching birth options with Ahimsa in mind is something that can create a tremendous liberation of creative energies, freeing the potential of birth & early parenting to be a peaceful experience for the human family at large…

What’s the real reason behind lotus birth? Homebirth and other fringe birth advocates are engaged in a battle of oneupsmanship, and the woman with the most bizarre (and often the most dangerous) birth practices wins.

So, for example:

A says, “I had natural childbirth”
and B says, “Oh, yeah, well I had PAINLESS childbirth”
and C says, “Well, ladies, I can top that. I had an ORGASM during childbirth!”

and:

A says, “I had my baby in a birth center”
and B says, “Oh, yeah, well I had my baby at HOME”
and C says, “Well, ladies, I can top that. I had my baby at home BY MYSELF!”

now:

A says, “My partner cut the cord”
and B says, “Oh, yeah, well we waited until the cord stopped pulsating and then cut the cord”
and C says, “Well, ladies, I can top that. We didn’t cut the cord AT ALL and just waited for it to rot off!”

On this point I agree with homebirth and other fringe birth advocates. If the goal is to claim the wackiest childbirth practice, lotus birth wins: treat your baby like a “flower” and let the dead parts rot off.

This piece first appeared in May 2009.

Enjoy!

Unassisted birth advocate Rixa Freeze ponders how different women can view epidurals very differently:

Epidural + empowerment are two words that don’t always get put together in the same sentence, even among women who gladly choose epidurals for pain relief. For me–huge caveat that I’m speaking about my own thought processes here, not generalizing myself onto all women–an epidural is the opposite of empowerment. Not just emotionally or psychologically, but in the literal sense, too, because an epidural causes full or partial paralysis from the waist down. The thought of losing sensation, of literally being unable to walk or move, isn’t something I would look forward to in labor. To me, labor = movement. I cannot imagine having a contraction without moving in response to it.

She views epidurals as disempowering because they limit movement and sensation, yet there are many women who find them empowering because they eliminate pain. Dr JaneMaree Maher of the Centre for Women’s Studies & Gender Research at Monash University in Australia,offers a very different way of conceptualizing pain and empowerment, one that resonates with the majority of women. In her article The painful truth about childbirth: contemporary discourses of Caesareans, risk and the realities of pain , she observes:

… Pain will potentially push birthing women into a non-rational space where we become other; ‘screaming, yelling, self-centered and demanding drugs’. The fear being articulated is two-fold; that birth will hurt a lot and that birth will somehow undo us as subjects. I consider this fear of pain and loss of subjectivity are vitally important factors in the discussions about risks, choices and decisions that subtend … reproductive debates, but they are little acknowledged. This is due, in part, to our inability to understand and talk about pain.

As she explains:

… [W]hen we are in pain, we are not selves who can approximate rationality and control; we are other and untidy and fragmented. When women give birth, they are physically distant from the sense of control over the body that Western discourses of selfhood make central; they are very distant from the discourses of choice that frame the caesarean rates debate. I am not suggesting here that women become irrational in childbirth … I am however suggesting that we continue to frame birthing experiences and decisions as if that model of subjectivity were the relevant one and in so doing, we move further away from articulating the realities of birthing, of pain and of the ways in which women engage.

So epidurals, as the most effective form of pain relief, give women control over their own bodies and control over the way in which they behave. This allows women to represent themselves to others in the ways in which they wish to be seen, instead of pushing them into a “non-rational” space.

While women like Rixa value the ability to move above all else, and therefore consider forgoing an epidural empowering, most women value the ability to control their own bodies and control the way that they behave. For them, pain is disempowering because it robs them of the control they value, and robs them of the ability to articulate other desires or even speak.

The bottom line is that there is nothing inherently empowering about pain or pain relief. It depends on what each individual woman values and wishes to control. Wanting to move in labor is no more or less important than wanting to be comfortable in labor. Women who choose epidurals find them very empowering.

This piece first appeared in February 2010.

The last year has been pretty tough for Canadian family practice professor Dr. Michael Klein.

Dr. Klein is a darling of the natural childbirth establishment because, among other things, he opposes epidurals. He is sure with every fiber of his being that epidurals interfere with labor. Too bad that the scientific evidence shows the opposite. Now Dr. Klein has concluded it’s time to thrown out the scientific evidence.

You may recall that Dr. Klein routinely delegitimizes women’s need to relieve the agonizing pain of labor. In a 1200 word post about epidurals on the increasingly irrelevant Lamaze blog Science and Sensibility, Dr. Klein utterly failedto mention the excruciating pain of childbirth.

In a subsequent post Dr. Klein asked if epidurals change labor. He acknowledged that the scientific evidence suggests they do not. Then he tells us what he personally found in his research on epidurals and why he believes that and chooses to ignore the Cochrane Review that showed epidurals have no impact on the C-section rate.

In fact, Dr. Klein is pretty disgusted with women in general, not simply for their choice of epidurals, but because they reject the entire shaky edifice of natural childbirth philosophy. Dr. Klein falls back on the usual NCB excuse. Those women are uneducated about childbirth decisions. What worse, they accept medical advice from their own obstetricians!

For his troubles, Dr. Klein was publicly chastised by the Society of Obstetricians and Gynecologists of Canada (SOGC), an organization with which he has worked closely. In an unusual step, the SOGC issued a position paper condemning Klein personally for his shoddy and irresponsible conclusions.

But Dr. Klein does not quit. As the mounting evidence produced by meta-analyses and randomized controlled trials shows epidurals, even early epidurals, do not increase the rate of C-sections, Dr. Klein has decided to attack the very notion of evidence based practice.

In a paper entitled The Tyranny of Meta-analysis and the Misuse of Randomized Controlled Trials in Maternity Care published (where else?) in the journal Birth, Klein expresses his peevishness.

Here’s the abstract:

Recent meta-analyses of key areas in maternity care have covered home birth and epidural analgesia. In each of these cases serious issues have arisen from the use of subjective inclusion and exclusion criteria, heterogeneity of included studies, and inclusion of studies that were conducted in settings that were not representative of usual maternity care. This latter flaw is especially notable for early epidural analgesia, where study environments with very low cesarean section rates are included. Such study settings lack external validity and have raised concerns about the political uses of meta-analysis…

Why is Dr. Klein upset? He doesn’t like a recent study published in the British Journal of Obstetrics and Gynecology entitled Early versus late epidural analgesia and risk of instrumental delivery in nulliparous women: a systematic review by Wassen et al. The study comes from the Netherlands. As the authors note:

… The introduction of a national guideline in the Netherlands in 2008 on the management of labour pain resulted not only in an increase in EA [epidural analgesia] requests, but also those requests being made at an earlier stage in the course of labour. Therefore we are interested in the effect of early EA strictly defined as 3 cm or less in the latent phase on the mode of delivery.

The main objective of this report was to review recent literature on the influence of this stricter definition of early EA (including combined-spinal epidural) compared with late EA in nulliparous women at 36 weeks or more of gestation, on the rate of caesarean deliveries or instrumental vaginal deliveries.

They are not the first to explore the issue:

… Results of randomised controlled trials (RCTs) and systematic reviews published
between 2002 and 2004 did not demonstrate any difference in the rate of caesarean deliveries between women who had received EA and women who only received intravenous analgesia. A Cochrane review, published, in 2005, showed that EA was associated with an increased risk of instrumental vaginal birth (pooled risk ratio [RR] 1.38, 95% CI 1.24–1.53) compared with deliveries with nonepidural analgesia or no analgesia.

A landmark study by Wong et al., published in 2005, provided evidence that early epidurals in comparison with late epidurals do not cause an increased rate of caesarean deliveries and instrumental vaginal deliveries in nulliparous women with spontaneous labour…

Wassen et al. searched for RCTs, prospective cohort studies and retrospective cohort studies in which the effects of early EA (cervical dilatation <4 cm) on the mode of delivery in nulliparous women have been studied. They found 6 studies comprising 15 399 nulliparous women in spontaneous or induced labor. Risk of caesarean delivery (pooled risk ratio 1.02, 95% CI 0.96–1.08) or instrumental vaginal delivery (pooled risk ratio 0.96, 95% CI 0.89–1.05) was not significantly different between groups. They concluded:

This systematic review of the literature showed no increased risk of caesarean delivery or instrumental vaginal delivery for women receiving early EA compared with late EA. Therefore, a woman’s request for EA early in labour cannot be rejected on the grounds of its presumed adverse influence on the mode of delivery. Consequently, the preference of the labouring women should be leading.

Dr. Klein, of course, disagrees. He shared his disagreement in a letter to the editor of BJOG that was systematically demolished by Wassen et al:

Dr Klein suggests that the meta-analysis is primarily about caesarean section, and that the title is therefore misleading. The primary focus of our meta-analysis was the effect of early epidural analgesia (EA) on the rate of instrumental vaginal delivery or caesarean delivery. Table 3 illustrated the inclusion of six studies (15 399 women) for the rate of instrumental delivery and five studies (14 836 women) for the rate of caesarean delivery. Thus, we disagree with Klein’s conclusion, and consider the title appropriate.

The fact that Luxman’s study was underpowered is irrelevant because the results were pooled with results from other studies. In addition, Klein refers repeatedly to the fact that there is a low caesarean section rate in several studies. He does not argue, however, about what would be the effect of a higher, versus lower, rate of caesarean section on the relative risk…

In Wang’s study, a minimum of 1-cm dilation was required to receive epidural analgesia in the early group, and results were compared with the late group in which dilation was at least 4 cm. We believe that Klein’s comment on the type of comparison in this study was unjustified.

Finally, Dr Klein expressed doubts about the external validity of Wang’s study to women in spontaneous labour. We, however, see no important difference between the outcomes of studies with spontaneous or induced labour.

Now Dr. Klein has taken the argument to the journal Birth where he can be fairly certain that no one will be able to point out the mistakes in his reasoning. He repeats his already discredited assertions and then goes on to editorialize:

… Missing from the discussion of epidural analgesia use in maternity care is the recognition of how this technology has completely transformed childbirth—sometimes for the better and sometimes with unintended negative consequences. Most of the new generation of medical and nursing staff have been educated in, and practice in, high epidural and high cesarean section environments. It is reasonable to assume that in such settings, skills for the support of women, absent epidurals, either atrophy or were never learned. Hence, it is likely that epidural analgesia applied early and on a routine basis, even employing the newer low dose (“walking”) epidurals, will contribute to the ever-increasing cesarean section rates — not as a single factor as randomized controlled trials have attempted to isolate, but as part of an overall technology-dependent approach.

In other words, randomized controlled trials, the gold standard in research, have failed to demonstrate that epidurals lead to an increase in C-sections. But, according to Dr. Klein, it’s okay to ignore them.

Klein then references one of his own discredited studies:

The Canadian provider maternity attitudes study demonstrated that the younger generation(<40 yr) of obstetricians were more likely to believe that epidural analgesia did not interfere with the progress of labor or result in more medical interventions when compared with their older colleagues. This finding was probably because the former were educated in the era of high-epidural use, compared with older practitioners, who saw the change that occurred when epidural analgesia was introduced.

No, Dr. Klein, it’s because the scientific evidence SHOWS that epidurals do not interfere with the progress of labor.

Comfort with, and dependency on, epidural analgesia by younger obstetricians and their anesthesia colleagues provide a fertile field for the unquestioning acceptance of randomized controlled trials and meta-analyses which appear to show that epidural analgesia, given early, does not increase the cesarean section rate.

So there you have it: Dr. Klein is sure that women who choose epidurals are uneducated and inappropriately influenced by their obstetricians. And he is sure that obstetricians are inappropriately influenced by the actual scientific evidence.

Instead of acknowledging that he is wrong, he has been forced to declare that everyone else in the world (mothers, obstetricians and research scientists) is wrong. At this point, Dr. Klein is simply making a fool of himself.

Valerie’s comment, found on this blog post:

“I think home birth is an ideal way to bring the blessing of a new life into the world, but certainly not the only way … I just know how fired up women can get on this topic!).

My story: I had five hospital births…the last one was a scheduled c-section because my OB/GYN wouldn’t attempt a version on a baby who was breech and estimated to be 10 1/2 to 11 lbs via ultrasound. I disagreed with her (having given birth to four large-ish sized babies, ranging from 8 lbs 5 oz to 9 lbs 8 oz at that point…all of whom who had been breech but either turned on their own or were manually turned through an external cephalic version and delivered vaginally), but ultimately felt like there was no other option and went through with the section…

My OB/GYN didn’t allow trial of labor after c-sections, so I was forced to find someone who would…my research led me to a wonderful midwife who only provided support for homebirthing mamas…

… I had a totally normal and text book pregnancy…at 40 weeks, 3 days we found out our first daughter was breech via ultrasound, despite my best efforts with chiropractic care during pregnancy to prove otherwise… so my midwife and I worked together and was able to get her head down…she stripped my membranes at my request and the next day my water broke and we prepared for my homebirth experience.

When my midwife arrived, I was already 8cm and in transition…but we found out our daughter had turned footling breech again. We prayed and had done our research and decided that the risks for a breech birth were low…especially given my previous ability to push out 8+ and 9+ pound kids, so we decided to move forward, knowing the risks…

Three hours later, my daughter’s cord prolapsed suddenly and within minutes I found myself and my midwife on a gurney en route to the ER. She died during the preparations for my emergency c-section and after 20 minutes of resuscitation attempts, the doctor finally pulled away from my daughter.

… I would do it all again…even knowing the outcome. For the first time in seven deliveries, I finally had the labor I knew I always could have had but never did. No IV’s…no being tied to a bed…no one telling me I couldn’t eat or drink…no one telling me when or when not to push…being able to have as many people in the room as I wanted…laughing and joking through the contractions with my friends and family surrounding me. I didn’t have that in the hospital.

… I will still cherish and forever hold my daughter’s “home labor” in my heart. I love to hear of the thousands of women who have perfectly normal and safe homebirths every year and wish the stereotypical OB wasn’t so anti-homebirth and anti-midwife…perhaps if the crossover between the two worlds wasn’t such an obvious one that few seem willing to cross, more women would be able to have the births they want rather than the ones they’re essentially told to have.”