In a post on Science and Sensibility, Henci Goer whines that no one is listening to childbirth educators, including herself:

I taught Lamaze classes independently from 1980 into the 1990s, yet … I quit because I could no longer stand watching my students lie down on the railroad track despite all I could do to tell them there was a train coming… More importantly, what more could—no, should—childbirth educators be doing about it, including hospital-based educators? …

What should they do about it? They should stop pretending that your birth is their business. They should stop looking to your birth for validation of their choices.

As I wrote last year, Lamaze is well aware that their message does not resonate with American women. Instead of examining the message, they are hiring public relations experts to promote the message more aggressively.

It reminds me of nothing so much as a dominating, interfering mother.

You know the type: the mother who believes that every choice her daughter makes is a statement about the value and correctness of the mother’s personal choices. The mother who believes that her daughter’s choices are not merely different, but a personal reproach. The mother who believes that it is her mission in life to convince her daughter to do it her way. If the daughter doesn’t do it her way, she just yells louder.

And, as is often the case with the domineering, interfering mother, she starts with the premise that if her daughter only understood the intrinsic wisdom of her mother’s choices, she would copy them. But Goer and her Lamaze compatriots, like many domineering mothers, have a problem. Most women refuse to accept that an intervention free birth is the only “normal” or “natural” way to have a baby.

According to Sharon Dalrymple a past president of Lamaze:

Indeed, the research showed that the meaning of the words “normal” and “natural” was not interpreted by the women and educators the same way. For example, 36% of women felt that ALL vaginal births are “normal birth”, while 63% of Lamaze Certified Childbirth Educators defined “normal birth” to be a birth without medical intervention. Women and Lamaze childbirth educators are likewise divided when deciding if the terms “natural birth” and “normal birth” are generally similar or generally different in meaning.

Lamaze tries to trade on the cultural assumption that “normal” and “natural” are intrinsically superior and that, therefore, “normal” and “natural” could be used as code words for “best.” Evidently some daughters women are too dense to make the connection so coded appeals must be dismissed in favor of more overt declarations:

Lamaze International found that the words safe and healthy are the most effective words for communicating and promoting the birth practices Lamaze has endorsed for years. Everyone wants a safe and healthy birth. Mothers are particularly motivated to keep their baby and themselves safe and healthy…

Just like a domineering, interfering mother, Goer and Lamaze want you to know that their choices aren’t merely the best choices, they are the safest and healthiest choices. Just like a domineering mother, Lamaze declares: if you really cared about your baby’s health and safety, you’d do it my way.

Not only is this as obnoxious as any interfering mother who proclaims the superiority of her personal choices, it is just as wrong. The practices that Lamaze declares to be the safest and healthiest are nothing more than their personal preferences.

Consider some of the 6 “best” practices that Lamaze promotes:

Let labor begin on its own: There is no scientific evidence that a spontaneous labor is better or safer for babies. Indeed, there is copious scientific evidence that the risk of stillbirth begins increasing before 38 weeks and rises steadily with each day that passes. That risk must, of course, be balanced against any risks of induction to the mother, but, even so, it is factually false to claim that spontaneous labor is safer. Indeed, as the rate of induction has risen in the US, the rate of late stillbirth has fallen dramatically.

Walk, move around and change positions throughout labor: There’s no scientific evidence that moving around or changing positions has any impact on labor, let alone a beneficial impact. According to the Cochrane review on position in labor:

There were no differences between groups for other outcomes including length of the second stage of labour, mode of delivery, or other outcomes related to the wellbeing of mothers and babies.

Avoid interventions that are not medically necessary: In other words, refuse an epidural; yet there is no scientific evidence that childbirth without pain relief is better, safer, healthier or superior in any way to childbirth with pain relief. No matter. The women at Lamaze think that they are superior for refusing pain medication, so you should refuse it, too.

Goer and her compatriots at Lamaze sound just like the domineering, interfering mother who tells her adult daughter: do it my way because my way is best. And as in the case of the domineering interfering mother, the adult daughter should ignore the remonstrances and reproaches, recognizing that they have nothing to do with the daughter’s well being and everything to do with the mother’s validation.

It sounds like that is just what happened to Goer. Women ignored her remonstrances and reproaches, recognizing that they have nothing to do with the well being of women and babies and everything to do with Goer’s desire to validate her own choices.

The internet is a tremendous source of health information. Unfortunately, it is also a tremendous source of misinformation. How can a lay person tell the difference?

I’ve designed the following scoring system to distinguish between factual information about childbirth, and the pseudoscience and made up mumbo-jumbo that passes for “knowledge” among natural childbirth and homebirth advocates.

If a website or publication does not get a grade of at least 50 points out of 100, you should ignore the site as worthless or worse, an active purveyor of falsehoods. The beauty of this system is that it is not restricted to websites. The same evaluation process can be used for books, pamphlets, editorials, etc.

Every site is given 100 points to start. Points are subtracted as follows; it is possible to end up with negative points.

1. Subtract 80 points if it is written by a lay person.

For the life of me, I cannot understand how anyone could be gullible enough to follow medical advice from a layperson.

2. Subtract 70 points if is written by a doula or childbirth educator. Subtract 50 points if it is written by a direct entry midwife.

Doulas and childbirth educators are paraprofessionals who lack direct experience with patient care. Looking to them for medical advice about childbirth is like asking a stewardess for advice about aerodynamics.

Direct entry midwives (like CPMs) are pseudo-professionals. They lack the minimal education and training required by midwives in every other first world country and are considered unqualified to practice in every other country in the industrialized world. They are birth “hobbyists” who like to attend births but couldn’t be bothered to get a real degree in midwifery.

3. Subtract 40 points if it makes the claim that women were “designed” to give birth.

In the first place, no one is “designed.” We are products of evolution and evolution favors survival of the fittest, NOT survival of the perfectly fit. In the second place, to the extent that you wish to use such language, every part of the body is “designed” for specific functions, but that doesn’t mean they are always performed correctly. Eyes are “designed” to see, but that doesn’t prevent a large proportion of the population from being nearsighted.

4. Subtract 40 points if it insists that sanitation is responsible for the massive drop in neonatal and maternal mortality.

The great developments in sanitation (and the drops in general mortality that followed) occurred in the late 1800’s with the discovery of the germ theory, and the implementation of public health measures like clean water, sewers, etc. The precipitous drop in both perinatal and maternal mortality did not start until the late 1930’s with the advent of antibiotics, blood banking and improved anesthesia.

5. Subtract 30 points if it makes the claim that “obstetricians” are surgeons.

Just because someone knows how to do surgery doesn’t mean they will do it for every case they see. Ophthalmologists are surgeons, but they do surgery as a last resort. Dermatologists are surgeons, but you wouldn’t hesitate to see one to check for precancerous lesions. Ear, nose and throat specialists are surgeons, but you wouldn’t hesitate to see one for problems with your ears, nose or throat.

6. Subtract 100 point if it includes “birth affirmations.”

Birth affirmations are an endorsement of magical thinking, the belief that our thoughts have the power to cause various events. Magical thinking has no place in science.

7. Subtract 80 points if it claims that childbirth outcomes are affected by “fear.”

That is a racist, sexist claim made up by Grantly Dick-Read, the father of natural childbirth, to back up his lie that “primitive” (read black) women gave birth without pain.

8. Subtract 50 points if it mentions “pathologizing birth.”

Childbirth is and has always been, in every time, place and culture, a leading cause of death of young women, and the leading cause of death in the entire 18 years of childbirth. The “natural” death rate in childbirth is about 1% for women and 7% for babies. Obstetrics is about preventing those “natural” deaths.

9. Subtract 20 points if it claims that the World Health Organization recommends a C-section rate between 10-15%.

The World Health Organization quietly withdrew that claim in 2009, acknowledging that there was NEVER any evidence to support it.

10. Subtract 40 points if it claims that the Netherlands has excellent mortality rates.

The Netherlands, the first world country with the highest rate of homebirth, as one of the worst perinatal mortality rates in Western Europe and poor maternal mortality rates.

11. Subtract 50 points for the claim that puerperal sepsis (childbed fever) would have been eradicated if only people hadn’t ignored Semmelweis.

Semmelweis did not publish his findings for nearly 20 years, probably because he was battling serious mental illness. When he did publish, his writing was extremely difficult to understand and the key point was buried within reams of text.

12. Subtract 30 points if it includes the claim that “good nutrition” improves pregnancy outcomes in any place besides the developing world.

There is NO scientific evidence that nutrition plays any role in pregnancy outcomes in first world countries, with the exception that folate supplementation reduces the incidence of neural tube defects like spina bifida.

13. Subtract 50 points if it claims that “no study has ever proven hospital birth to be safe.”

No study has ever proven in hospital surgery is safe than home surgery, but that doesn’t mean that it isn’t.

14. Subtract 40 points for the claim “babies die in hospital, too.”

The issue is not whether babies die. As I’ve already pointed out, childbirth is inherently dangerous. The key point is that FEWER babies (proportionally) die in the hospital.

15. Subtract 30 points if it includes an anecdote about obstetric malpractice in a hospital. Subtract an additional 20 points if that episode of malpractice has been official punished.

Malpractice can occur any time human beings are involved. There is no evidence that there is more malpractice among obstetricians than among midwives. The difference is that hospitals and medical boards have systems of accountability. Homebirth midwifery does not hold midwives accountable for the tragedies that occur at their hands.

16. Subtract 20 points for mention of Dutch midwifery studies without also mentioning that Dutch midwives delivering low risk patients have higher mortality rates than Dutch obstetricians delivering high risk patients.

Moreover a recent study showed that Dutch midwives have a 30% higher mortality rate than Flemish midwives who work in hospitals just across the border.

This list is far from exhaustive; it merely hits the high points of the standard false or misleading claims of NCB and homebirth advocates.

To see how this rating system works, we can apply it to an opinion piece that appeared recently in The Sydney Morning Herald last week. It is written by celebrity Tara Moss (-80 points).

Here are the relevant quotes:

Childbirth is still seen by many as something best ”cured” by a doctor in hospital. (-50 points)

… the largest study conducted into home births (examining 529,688 births and published in BJOG: An International Journal of Obstetrics and Gynaecology (-20 points)

Some of the most important medical advances in the past century have had to do with proper sanitation. (-40 points)

Puerperal fever, or ”childbed fever”, took the lives of large numbers of mothers and babies for two centuries because – wait for it – doctors did not believe in washing their hands between patients and many even performed autopsies and delivered children without disinfecting their hands between. (-50 points)

… we now have a far better understanding of prenatal nutrition needs (-30 points)

we may as well use the tragic case of Grace Wang, who had antiseptic injected into her spine instead of an epidural in a mix-up at a Sydney hospital last year. (-50 points)

In the Netherlands, about 30 per cent of women give birth at home, providing the ideal opportunity for a long overdue large-scale study into its safety. (-40 points)

The score for Ms. Moss’ opinion piece? She started with 100 points, but when we subtract 360 points for false or misleading statements, the pieces ends up with -260 points. That’s an F by any stretch of the imagination.

With this system it’s easy to find out if a childbirth website or publication is providing accurate information or merely pseudoscientific mumbo-jumbo masquerading as “knowledge.” Just apply the simple criteria above to determine if a childbirth website is worthwhile or worthless.

Lay optometrists and their advocates are planning rallies at Department of Motor Vehicle (DMV) offices around the country today. They are protesting what they believe to be the coercive tactics of the DMV in mandating vision correction for drivers with less than perfect vision. Simply put, anyone applying for a license must submit to a vision test, and anyone who has been diagnosed with nearsightedness must wear glasses or contacts while driving.

Members of the group Optometrists Alliance of North America (OANA) think that is wrong.

According to their spokesperson Ima Frawde CPO (certified professional optometrist, formerly known as a lay optometrist), human eyes are designed by nature to see perfectly.

Are we really supposed to believe that 25% of the population needs vision correction? That’s simply laughable. We wouldn’t be here if nearsightedness were so common. We would have died out long ago.

And who would know better than certified professional optometrists “experts in normal vision”? Ms. Frawde explains that unlike real optometrists who spend years learning about pathological vision and work only in offices, CPOs are the only optometrists trained to provide vision care at home.

According to Ms. Frawde:

Many people don’t realize that CPOs carry the exact same equipment as regular optometrists, but instead of brief office visits once a year, CPOs provide home appointments each and every month to educate people about their vision options and talk about their “vision plan”

Dr. I. C. Yu, CPO, who runs the blog Vision Without Fear, explains the ten affirmations that lead to perfect vision:

Eyeglasses and contacts are unnatural. Nature never intended human beings to have vision correction.

Relying on natural vision instead of giving in to glasses is empowering. Anyone can drive safely wearing glasses. It is a true achievement to drive safely without them.

The requirement for a vision test for driving is absurd. All you have to do to drive it to see; it is hardly necessary to test every single person for vision impairment.

We need to trust vision. It’s time for us to reject the notion that human eyes are broken and need to be “fixed” by artificial means.

People should rely on their intuition about vision. If they believe that it is safer to drive without glasses, then they should drive without glasses.

Vision affirmations lead to better outcomes. Drivers should continually remind themselves, “I can see the car in front of me” and that will naturally improve their ability to see.

The decision to wear glasses is a choice. The DMV has no right to interfere with individuals’ right to make their own choice about whether they will wear glasses or contacts while driving, or even whether they will submit to the vision test when renewing their license.

Vision junkies are far more educated on the topic of vision than others. Most people behave like sheep when told that they need glasses for vision correction. They just go out and buy them, without ever questioning whether they are truly necessary.

There’s no scientific evidence that driving with glasses is safer than driving without. No one has even bothered to study it. Those in authority simply assumed that correcting nearsightedness is safer.

No one should underestimate the influence of “Big Glasses.” The vision industry is a multi-billion dollar industry. No one profits by declaring that you have perfect vision. Eyeglass manufacturers, contact lens manufacturers, optometrists and opticians only profit if you need vision correct. Is it any wonder that so many people are told they need glasses?

According to Dr. Yu, who is a professor of anthropology as well as a CPO:

It’s a travesty around the world that Western-style optometry have come in and annihilated long traditions of traditional optometrists. Lay optometrists peel away these fictions of medicalized eye care, exposing strong and capable women who “see” outside the regulatory and self-regulatory processes naturalized by modern, technocratic optometry.

Dr. Yu counsels:

The American people need to “take back vision” from those who have tried to intimidate us into believing that our eyes are broken. We should stop giving in to the perceived need to actually see the road and return to our natural roots. We must learn to see the way nature intended, without glasses and without contacts, and we will surely feel empowered as a result.

Adapted from a piece that first appeared in September 2009.

The Onion, a satirical newspaper, offers its take on homebirth midwives. Everything from the title, Upon Reflection, I May Have Exaggerated My Skills In Midwifery is spot on:

Okay, Helen, you’re doing great. Just remember to breathe. In… out. In… out. Fantastic. Just listen to the ocean-waves CD and try to relax. I think I can see the baby. Yeah, you’re crowning, and it looks—oh, holy Christ! It’s covered in blood! It’s supposed to be like that? I mean, of course it’s supposed to be like that. Of course. I remember that episode of ER. It was just like that.

“Expert”? I’m sorry. Let me clarify. I’ve wanted to try my hand at delivering a baby for a long time, and I thought it was time to give it a shot. Midwifery has been an interest of mine for months now, but the best way to learn is to roll up your sleeves and just do it. My advertisement said “expert”? I probably meant to say “enthusiast.” They both start with an “e.” It’s an easy mistake.

It looks like you’re fully dilated now. Well, I think that’s what’s happening. I know! I’ll call my sister and ask. She was going to school to be an obstetrician, but dropped out. Now she manages a Denny’s…

What? I don’t think I said that I’ve delivered hundreds of babies. You probably just misheard me. Are you sure? Well, then I meant I wanted to deliver hundreds of babies. And who wouldn’t? Childbirth is a miraculous thing. We’re ushering a new life into the world, the two of us, together.

Hm, it’s too bad I forgot to bring that stuff I printed out from the Internet…

Whoa, whoa, whoa. There’s no reason to panic. I know exactly what I’m doing. I looked through a book called All Creatures Great And Small. They delivered a calf in it. And I got a government pamphlet from Pueblo, Colorado. It was in Spanish, but I got the general feel…

Okay, I got a feeling that the rough stuff is almost over. The head is nearly out. Just one more squeeze and… Presto! …

Okay, okay. I’ll have to wipe some stuff off here first. Do you have a towel around here? There, thanks. Oh, girl. Definitely, this is a girl. We’re out of the woods. And you were worried!

Oh, sweet mother! There’s something else coming out. It’s—oh… my… God! It’s twins, but this one is… deformed. It doesn’t have eyes or arms or legs. It’s just a big sack of bloody goo. Let me check something here. No, it doesn’t seem to have a pulse. Just the umbilical cord. The other end goes to your baby. Pla-what? Placenta? Really?

Well, I’ll be. Learn from your mistakes, I always say.

Let me tie off your umbilical cord… and… okay, we’re good to go. You’ll want to spend some time with your darling little girl, so I’ll just mosey along, just as soon as I get my check.

Oh, and keep in mind that, if you ever need a nanny, I’m the best there is.

This piece first appeared on Homebirth Debate in June 2008.

The Birthplace Study, published just 3 weeks ago, is the largest, most comprehensive study of homebirth ever done. The authors summarized their findings as follows:

… [T]here was a significant excess of the primary outcome in births planned at home compared with those planned in obstetric units in the restricted group of women without complicating conditions at the start of care in labour. In the subgroup analysis stratified by parity, there was an increased incidence of the primary outcome for nulliparous women in the planned home birth group (weighted incidence 9.3 per 1000 births, 95% confidence interval 6.5 to 13.1) compared with the obstetric unit group (weighted incidence 5.3, 3.9 to 7.3).

In other words, the risk of death and serious injury was approximately double in the homebirth group and that increase was seen mainly among first time mothers.

There is a very significant limitation to this conclusion, however. 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.

Fortunately, the authors of the study have published nearly a thousand pages of supplementary material. Buried in part 4 of the supplemental material is the outcomes for those women who had homebirths but did not meet the very restrictive criteria of the study. Outcomes are compared to the low risk women electing hospital birth who also failed to meet the more restrictive criteria for inclusion in the study. It is instructive to look at what happened in those births.

Not surprisingly, the incidence of adverse events was higher in the homebirth group, even when compared with higher risk women who delivered in the hospital.

The first thing to note is that in contrast to the women who did meet the rigorous exclusion criteria, in which 73% (12,050/16538) were multips, among those who did not meet the criteria, fully 83% (1096/1324) were multips. That’s not surprising when you consider that multiparous women were required to meet an additional level of scrutiny; specifically they had to have had no complications in any previous pregnancy.

Second, homebirth doubled the risk of an adverse outcome for both nulliparous women and multiparous women in the higher risk group. That’s not surprising, either. Disregarding outcomes of previous pregnancies makes the two higher risk groups more comparable to each other that the two lower risk groups are to each other.

This is just further confirmation of the central finding of the study. Homebirth, doubles the risk of adverse perinatal outcomes. Therefore, the claim of the Royal College of Midwives and other homebirth advocates that “.., [f]or women having a second or subsequent baby … homebirths appear to be safe for the baby” is not true.

Moreover, the more grandiose claim of homebirth advocates that “50% of women” could safely have a homebirth is a complete falsehood. The Birthplace study actually shows that homebirth is only safe in rigorously screened low risk multiparous women who in addition to having no risk factors in this pregnancy, have had no risk factors in any pregnancy.

In other words, homebirth is safe only when nothing goes wrong. To ensure that nothing goes wrong, candidates for homebirth must be screened very rigorously. Anything that could be remotely considered a risk factor in the current or any previous pregnancy renders homebirth unsafe.

The basic reality of childbirth, that it is inherently dangerous, and that life threatening events can happen without any warning, is confirmed by the Birthplace Study. Homebirth is safe only when nothing goes wrong. Since there is no way to predict with complete accuracy whether something is going to go wrong, homebirth can never be as safe as hospital birth.

In 2003 the US standard birth certificate form was revised to include place of birth and attendant at birth. That makes it possible to compare neonatal death rates at home vs. in the hospital. The first data set (2003-2004) showed that homebirth had triple the rate of neonatal mortality as comparable risk hospital birth. The most recent data set shows was recently released by CDC Wonder and the results are appalling:

In 2007, American homebirth with a homebirth (non-CNM) midwife had a neonatal mortality rate 7.7 times higher than comparable risk hospital birth!

The table shows that the neonatal mortality rate for homebirths attended by an American homebirth midwives (CPM, LM) is 7.7 time higher than comparable risk hospital birth attended by a CNM (certified nurse midwife). This extraordinarily high death rate is all the more remarkable because it actually under-counts the homebirth death rate. That’s because homebirth transfers ended up in the hospital MD group and were not counted in the homebirth group. The real number of homebirth deaths is almost certainly significantly higher.

No wonder the Midwives Alliance of North American (MANA) continues to hide their death rates. How many of the 24,000 babies in their database of outcomes from 2001-2008 died at the hands of homebirth midwives? They won’t say, but the rate is probably comparable to, or perhaps even higher than this extraordinarily high rate.

Homebirth advocates having been crowing that the rate of homebirth has risen 20% from the early to late 2000’s, but the death rate, which was already unacceptably high, appears to have risen, too.

Homebirth with an American homebirth midwife kills babies. There is simply no question about it. Even the Midwives Alliance of North America knows that this is true. It’s time that American homebirth advocates stopped lying about the safety of homebirth and start doing something to reduce the number of preventable neonatal deaths.

Imagine a bicycle helmet designer who never considered issue of safety. He gives a great deal of thought to style, takes the issue of comfort into account and consider how best to market bicycle helmets, but simply assumes that protecting the cyclist’s head is irrelevant because cycling is inherently safe. That would be both foolish and bizarre, because in contrast to the designer’s belief that there is no need to worry about safety, head injuries are the major cause of mortality for cyclists.

Now imagine a homebirth midwife who never considered the issue of safety. She gives a great deal of thought to style considerations, ponders the issue of comfort in labor and even considers how best to market her services to clients, but simply assumes that childbirth is inherently safe. That would be both foolish and bizarre, because in contrast to the homebirth midwife’s belief that childbirth is inherently safe, it is actually inherently dangerous.

Nonetheless, homebirth midwives persist in the erroneous belief that childbirth is inherently safe. And that belief in something that is untrue renders the entire philosophy of homebirth midwifery incoherent and virtually nonsensical. Why do homebirth midwives persist in this belief? We can find insight in the chapter that I cited yesterday, The Dialectics of Disruption: Paradoxes of Nature and Professionalism in Contemporary American Childbearing by Northwestern University anthropologists Caroline Bledsoe and Rachel Scherrer.

Bledsoe and Scherrer explore the fundamental assumptions behind the philosophies of natural childbirth and homebirth. Bledsoe is a Professor of African American studies and the paper is in part of cross-cultural comparison of the bedrock assumptions that underlie beliefs about childbirth.

Homebirth midwives are obsessed with “disruptions” of the natural process of birth, because they lack a basic understanding of the purpose of and need for these “disruptions”:

Whether we look at birth through an African cultural vision, our own historical impetus for the rise of obstetrics as a medical specialty, or even through the lenses of international metrics, what emerges is a vision of birth as an event of potentially mortal consequence. The conviction among middle-class US women that birth is an event to be experienced to the full, freed from any external attempts to regulate or disrupt it, inverts this image. As we turn to the disruptions that preoccupy US middle-class women as they contemplate the birth of a child, it is vital to keep in mind both the dangers that reproduction can entail and the science that has allowed us to imagine as common sense a safe, uninterrupted. reproductive life trajectory. (my emphasis)

Simply put, the understanding of what is natural, and therefore the understanding of what is disruptive to the natural process is based on a false premise.

American women’s assumptions of a healthy, surviving mother and child make the possibility of apprehending birth as a pathological event a challenging stretch. The popular sources now overwhelmingly depict birth as a peak life experience of physicality for women, bringing a sense of achievement at fulfilling a natural act, so much so that the baby seems to play a secondary role. The failure to achieve all the elements of this experience is viewed as personal failure…

In fact, homebirth midwives know so little about childbirth that they actually believe that efforts to prevent “disruptions” are what makes childbirth safe.

… In the US, where the default assumption of pregnancy and birth is normality, a natural lifestyle during pregnancy and an intervention-free, natural birth are often described as the cause of a normal outcome: healthy mother and baby.

Since the safety of childbirth is assumed, NCB and homebirth advocates turn their attention to “disruptions” that they believe can lead to the two most feared outcomes.

1. The “suppressed birth experience”

While birth is seen as a natural process that should transpire at a pace and in a manner set by a birthing woman … birth is removed to the hospital, where … birth becomes subjected to … systematic management… [W]hat [NCB and homebirth advocates] most fear is losing control over the birth event and with it, the chance of achieving what they see as a natural birth… In this context, then, disruptions refer less to unpredictable events that can spell health risk … than to the disruptions that the loss of control to medical authority may spawn.

2. The failure to bond with the baby

Bonding has a deep emotional pull in the contemporary US… [Homebirth and NCB advocates believe that] [t]he faster the mother and baby … can establish dose contact-the mother receiving the infant immediately after birth, wet and crying, umbilical cord attached, placing it on her chest and beginning to breast feed-the better the chances of selling the child securely on a healthy emotional course in life … [T]he loss of the smallest window of bonding opportunity after the birth may set the stage for future pathology for both the infant and the new family unit.

Unbeknown to homebirth midwives, it is the “disruptions” that have allowed homebirth midwives the luxury of pretending that facilitating experience of childbirth and “meaning making” about childbirth are the most important services that can and should be offered.

… the explicit goal of childbearing in the us in the past was health normality. and in much of the developing world it remains the same. Today in the US, as long as health normality remains the predicted outcome, the goal shifts to the experience itself of childbirth, and the interventions that can save lives are [barely mentioned] in pursuit of the goal of naturalism and the control that is seen as the key to achieving it.

One of the most remarkable things about Melissa Cheyney’s paper Reinscribing the Birthing Body: Homebirth as Ritual Performance (discussed here) is the virtual absence of any discussion on safety, either of homebirth or of birth itself. The paper has 156 mentions of midwives/midwifery/providers, but only 13 of safe/safety. Safety is assumed to be a given. It is precisely this assumption, belied by everything we know about childbirth in nature, that is the fatal error at the heart of homebirth midwifery. Fatal because it renders the entire philosophy incoherent and nonsensical and fatal to the babies whose mothers have been misled by an incoherent and nonsensical philosophy.

Yesterday I wrote about Melissa Cheyney’s disquisition on the anthropology of birth. Cheyney does provide insight into the “meaning making” of natural childbirth and homebirth advocates, but she does so from a position of complete credulousness. Since she (herself a homebirth midwife as well as an anthropologist) is part of the subculture she is investigating, she does not question the meanings, the meaning-making or the relationship of such meaning-making to reality. It as if an anthropologist writing on human sacrifice ascribed to the belief that the gods could be propitiated by throwing virgin girls into volcanoes, and having accepted that assumption, proceeded to describe the meaning and meaning-making of the ceremonies surrounding the sacrifices.

Cheyney, however, is not the only anthropologist of birth. There are others whose work is not colored by the need to justify the beliefs of the natural childbirth/homebirth subcultures. Consider the chapter The Dialectics of Disruption: Paradoxes of Nature and Professionalism in Contemporary American Childbearing by Caroline Bledsoe and Rachel Scherrer. It appears in the book Reproductive Disruptions: Gender, Technology, and Biopolitics in the New Millennium.

The chapter covers many areas of the anthropology of childbirth in contemporary first world countries. The one that is relevant for our current discussion is the issue of meaning-making explained by Cheyney. However, they go far beyond Cheyney in that they explore why and how NCB/homebirth advocates have come to believe what they do. Unlike Cheyney, who so eagerly accepts the meanings and meaning-making of contemporary NCB/homebirth advocates, Bledsoe and Scherrer examine why meaning-making is so important within the subculture.

Their description of the current situation is spot on:

… Birthing is depicted culturally as an individual achievement, one in which a woman should be in control of her actions. For this, women attempt to present themselves as professionals, medical as well as legal: as close as they can come to being equals with their medical peer doctors, informed and trained to evaluate their qualifications (my emphasis).

Bledsoe and Scherrer recognize that meanings and meaning-making are luxuries of a society in which childbirth is so safe that women have forgotten that in reality it is inherently dangerous:

… As childbearing became safer and more benign visions of nature arose, undesired outcomes of birth for women came to consist of a bad experience and psychological damage from missed bonding opportunities. Today, with safety taken for granted, the new goal has become in some sense the process itself: the experience of childbirth… (my emphasis)

In other words, as I have written repeatedly since for NCB/homebirth advocates outcome is taken for granted, the focus has shifted entirely to process. And the most critical element in the process, the one to which the most significance is imputed, is control.

Their critical insight:

… But with *control* being such a crucial issue in cultural ideals of childbearing, the greater the expectations that a scripted birth plan creates, the greater the surety that the woman will fall short of her ideal. Some elements will go wrong, and with them the hope of remaining the equal of the professionals who deals with her birth. This relegates obstetricians, who have the power to disrupt a naturalism but also to save lives if something goes wrong, to being the inevitable targets of opposition. (my emphasis)

Specifically:

If nature is defined as whatever obstetricians do not do, then the degree to which a birth can be called natural is inversely proportional to the degree to which an obstetrician appears to play a role. The answer to why obstetricians are described with such antipathy thus lies not in the substance of what obstetricians do that is unnatural – whether the use of sharp incision. forceps, and medications that blunt sensation. or anything else- but in the fact that obstetricians represent a woman’s loss of control over the birth event. Obstetricians are thus perceived as the chief source of disruption in the birth event, backed by the licensing power of medicine and the law. And yet it is not what obstetricians do that women find problematic but the fact that they are the people who step in when the woman is seen to have failed. (my emphasis)

In other words, as I have written repeatedly, the “natural” in natural childbirth has nothing to do with nature. Natural is defined as anything a midwife can do. In contrast, if only an obstetrician knows how to do it, it is “unnatural” by definition in the NCB subculture.

The authors summarize:

… Today, because of medical and technological advances that have brought so many of the life-threatening complications of childbirth under control, the naturalism in childbirth that women now envision is not only benign but desirable. But to the extent that childbearing remains less about nature than control, animosity will likely continue to be directed at doctors because they represent failure to attain nature, and animosity will continue to be directed at obstetricians, regardless of what they actually do or what their gender is. (my emphasis)

Ultimately, there is nothing wrong with Cheyney’s attempt to describe the meanings and meaning-making of contemporary NCB/homebirth advocates. The problem is that she fails to question the fundamental assumptions that undergird these meanings. Just as human sacrifice only makes sense to those who believe that the gods are pleased by throwing virgins into volcanoes, natural childbirth only makes sense to those who believe that childbirth is inherently safe. And while we have no idea whether there are “gods” and whether they are pleased by human sacrifice, we do know that childbirth is not inherently safe.

Bledsoe and Scherrer understand:

… As we turn to the disruptions that preoccupy US middle-class women as they contemplate the birth of a child. it is vital to keep in mind both the dangers that reproduction can entail and the science that has allowed us to imagine as common sense a safe, uninterrupted, reproductive life trajectory.

It is precisely these points, the inherent dangers of childbirth, and the science that has allowed us to treat and prevent them, that Cheyney fails to take into account. Therefore, her analysis is flawed to the point that it is nearly nonsensical.

First I have to catch my breath from laughing so hard. I try not to spend large amounts of time wading through complete bullshit, but as a service to my readers, I bought and read Melissa Cheyney’s latest attempt at academic relevance. I ought to try it more often; it’s really funny.

And I did learn something important. Anyone who believes the oft repeated claims that homebirth midwifery is about scientific evidence is at best naive, and at worst a fool.

Melissa Cheyney makes clear, in her new paper published yesterday in the Medical Anthropology Quarterly, Reinscribing the Birthing Body: Homebirth as Ritual Performance, that homebirth is about anything but the scientific evidence.

Cheyney’s paper is a celebration of the crap that passes for “research” among homebirth advocates:

… As a socially performed act of differentiation, homebirths are constructed in opposition to dominant ways of giving birth, although just where the lines between consent and resistance lie are not always clear, shifting with each provider and each mother, over time and in the retellings.

Now don’t you feel silly; homebirth is not about birth or babies. Melissa Cheyney confirms what I have been saying for years. Homebirth is about defiance of authority. Of course that begs the question of what Melissa Cheyney is doing as Head of the Oregon Board of Direct Entry Midwifery. How trustworthy is a regulator whose stated aim is to create ritual performances in opposition to standard practice?

You might have thought that prenatal and intrapartum care was about delivering healthy babies to healthy mothers. How tragically naive; it’s all about peeling away fictions:

Midwives describe the desire to peel away these fictions of medicalized prenatal care, exposing strong and capable women who “grow” and birth babies outside the regulatory and self-regulatory processes naturalized by modern, technocratic obstetrics…

In other words, homebirth midwifery is not about what is actually happening, it’s all about pretending that women are strong and capable even when they are ill or their babies are dying.

Indeed:

The midwives who participated in this study openly reject the messages of danger, uncertainty, fear, “tentative pregnancy,” doctor-as-ultimate-authority, strangemaking, and even, to some extent, the separation they believe are communicated by the rituals of medicalized prenatal care…

But if homebirth midwifery is all about banishing messages of danger, uncertainty or fear (even when they are justified), why do homebirth midwives ape the practices of real medical professionals? Cheyney attempt to dazzle us with BS:

The use of prenatal artifacts—equipment for taking blood pressure or for urinalysis, for example—are thus, embedded in the larger power/knowledge matrices of midwifery–obstetric practices. The context, artifacts, and symbolic actions associated with prenatal care function to stack or layer meanings for participants by providing a text and subtext that are simultaneously both literal and metaphorical.

Uh-huh. Evidently that means that homebirth midwives monitor pregnant women NOT because such monitoring provides valuable information to be acted upon as necessary, but simply because it is a ritual that women expect. For homebirth midwives, pretending is far more important than reality.

… Repeated restylizations of the strong, capable, healthy pregnant body in the home communicate connection, safety, and well-being. These reconstructed “natural facts,” while equally socially embedded relative to more medicalized perspectives, are seen by midwives as essential components of the foundation needed for “trusting birth outside the hospital” once labor begins.

In case anyone is confused about what’s really important, Cheyney approvingly quotes a homebirth midwife:

I hope no doctors or midwives are running around thinking all we want is a live baby and mother…

Believe me, I’m not confused on that point!

There’s so much nonsense in this paper that, in the interest of brevity, I’ll offer a few more representative quotes.

On active labor:

… The physiological processes of labor transport women into an inherently liminal space—called “laborland” by mothers and midwives in this study—that carries its own affectivity. During labor, midwives can capitalize on this affectivity to transmit transgressive values about pregnant and birthing bodies, socializing participants into accepting the powerful and life-giving properties of the female body and the unity of mother and baby.

On upright pushing:

… It co-opts and restructures what Babcock has called “symbolic inversion,” where the gradual psychological opening to new messages characteristic of the liminal or transitional period of ritual is intensified by metaphorically turning elements of the normal belief system upside-down or inside-out.

On delayed cord clamping:

Midwives tend to feel very strongly about how the immediate postpartum period should unfold and argue that it is cruel to sever the cord too early.

On neonatal resuscitation:

… [M]idwives advocate for some practices that differ from mainstream hospital resuscitation rituals. For example, midwife participants argued that resuscitation is not simply the physiological process of assisting ventilation. Infants are seen as active participants in the process and, like adults who can be called back to consciousness after fainting by stimulation and speaking of their names, respond quickly to maternal touch and voice. Midwives, thus, encourage mothers to “call their babies back,” to caress and to speak to them as they are resuscitated.

Homebirth advocates routinely complain about the centrality of the doctor in “technocratic” births. Curiously, in homebirth midwifery the mother is not the central actor, the homebirth midwife is. A woman can’t simply be pregnant, labor, give birth or welcome her new baby. Every aspect of the process must be mediated by midwives whose primary purpose appears to be to transmit transgressional messages.

One aspect of birth — safety — is almost entirely absent from Cheyney’s discussion. Homebirth is not about birth and it is not about babies, so safety is irrelevant. It’s all about counter hegemonic empowering values!

… the rituals of homebirth midwifery care are not simply about assuring personal transformation via the transmission of counter hegemonic–empowering value —although many women certainly described their experiences this way. Midwifery rituals, as I have argued, are also self-consciously political in their intent. As the popular bumper sticker “Midwives: Changing the World One Birth at a Time” suggests, homebirth is a performative medium for the promotion of social change.

Actually, what it is really about is self-proclaimed midwives making themselves stars of the ritual “performance”:

… Capitalizing on the semiotic potential, heightened emotion, and the liminality of the birth itself, midwives seek to overturn mechanistic views of the faulty female body in need of medical management, replacing them with the language of connection, celebration, power, transformation, and mothers and babies as inseparable units. Homebirth practices, thus, are not simply evidence based care strategies. They are intentionally manipulated rituals of technocratic subversion designed to reinscribe pregnant bodies and to reterritorialize childbirth spaces and authorities. For many, choosing to deliver at home is a ritualized act of “thick” resistance where participants actively appropriate, modify, and cocreate new meanings in childbirth.

This paper is Exhibit A in why Melissa Cheyney is grossly unqualified to head the Oregon Board of Direct Entry Midwifery. For her, homebirth is all about three things: the midwife, the midwife’s beliefs and the midwife’s “performance.” Birth, babies and safety have little or nothing to with homebirth.

Evelyn Muhlhan, CNM was suspended by the Maryland Board of Nursing on October 7. According to the story in the Catonsville Patch:

The Maryland Board of Nursing has suspended the license of Catonsville-based midwife Evelyn D. Muhlhan, citing multiple complaints in recent years alleging she performed home births without a physician backup or an approved medical plan.

It seems that Muhlhan was too busy trusting birth to pay attention to the standards of practice. The suspension order is chilling reading, recounting as it does the various complaints made against Mulhan:

Case #1 (baby requiring expert resucitation):

On or about July 16, 2008, the Board received a complaint regarding Respondent from MD l, a neonatologist at Hospital-A.

According to the complaint, on June 7, 2008, Respondent performed a vaginal home delivery and the patient (“Patient A”) was reported to have experienced a pregnancy with contraindications for a home vaginal delivery, including, a previous c-section, Factor V Leiden deficiency and maternal obesity…

On arrival at Hospital A, the baby was described as cyanotic and apneic with no respiratory effort and was intubated and admitted to the NICU. with diagnoses of respiratory distress and perinatal depression. The baby was discharged home on June 27, 2008.

When interviewed by the Board’s investigator regarding the complaint, Respondent indicated that Collaborating MD-2 was her collaborating physician for home births.

During his interview with the Board’s investigator, Collaborating MD-2 was adamant that he does not cover Respondent for home births and that he “never has covered and never will” and has made this clear to Respondent on several occasions.

Patient #2 (baby with hypoxic ischemic encephalopathy and seizure disorder):

On or about April 14,2010, the Board received a complaint from … Director of Labor and Delivery and … Director of Gynecology and Obstetrics, at Hospital B. According to the complaint, between March 25th and 26th, 2010, Respondent failed to follow the standard of care in her management of an attempted home birth by:

I. Utilizing Intramuscular Oxytocin to stimulate labor in a term pregnancy;
II. Using fundal pressure in the second stage of labor to attempt to cause descent of
the fetus;
III. Using vaginal chlorhexadrine, rather than intravenous penicillin, in labor to treata known group B beta hemolytic strep vaginal carrier to prevent early onset GBS neonatal sepsis;
IV. Misdiagnosing fetal station resulting in an unnecessary episiotomy. The physical exam on admission to Hospital B was a fetus impacted in the vagina at + 1 station which was incompatible with the report that the fetus had been crowning when the episiotomy was performed…

… Patient B delivered a male infant (“Baby B”) by LSTCS, with a vertex fetal presentation and occiput posterior (“OP”) position at birth. The APGAR scores were 1 at 1 minute and 5 at 5 minutes and cord/Initial blood gas was ph 7.1; pC02 63; p02 10; BE -13. Baby B was limp and cyanotic on delivery with nuchal cord x 1, required PPV for 3 minutes before being transitioned to CPAP. Baby B was transported to the NICU on CPAP with diagnoses of Hypoxic Ischemic Encephalopathy and Seizure disorder.

Baby B was transferred to a pediatric rehabilitation hospital on April 21, 2010.

Patient #3 (attempted homebirth of 11 pound baby):

On May 31, 2011, the Board received a complaint from … Hospital C. The complaint alleged that on January 5,2011, Patient C presented to Hospital C after a failed home delivery by Respondent…

The complaint expressed concerns regarding: an attempted home birth when an estimated fetal weight of 11 lbs. was identified two weeks prior to labor; an attempted home birth with a mother with gestational hypertension; continued assistance of a patient at home with a protracted labor pattern.

…[O]n admission, Patient C was in active labor, dilated at 5 cm, 100% effaced and the fetal vertex was at – 4 station. The fetal heart rate was reassuring and the mother’s vital signs were stable. A plan of care was discussed with the patient and a decision was made to proceed with a cesarean section due to arrest of labor and a ultrasound estimated fetal weight of greater than eleven pounds.

On January 6, 2011 at 0147, a live male infant was delivered by primary c-section. APGAR scores were 1 and 8 at 1 and 5 minutes respectively, and the infant weighed 10 lbs and 9.6 ounces.

Patient #4 (attempted VBAC, uterine rupture, intrapartum death):

On or about July 14, 2011, the Board received another complaint from … Hospital C. The complaint alleged that on July 12, 2011, Patient D presented at Hospital C, after an aborted home birth, with uterine rupture, intra-partum fetal death and a history of a previous c-section…

On arrival at Hospital C, the patient was evaluated in the ER and taken immediately to the OR. Several unsuccessful attempts were made to obtain a fetal heart rate.

On July 12, 2011 , Patient D underwent a low transverse c-section. Operative Findings include: … male infant in vertex presentation, occiput posterior with a tight nuchal cord. Mother had an area of uterine rupture from the scar from the midline to the right side going down toward the cervix and uterine vessels on the right side. Abundant thick meconium was noted in the patient’s abdomen and pelvis with massive bowel edema and erythema, with meconium already stuck onto bowel walls.

Patient #5 (postpartum hemorrhage, attempted manual removal of placenta at home):

On September 8, 2011, the Board received a complaint from the Risk Manager at Hospital C regarding Patient E. According to the complaint, Patient E was admitted to Hospital C on September 7, 2011 after a home delivery and suspected manual extraction of the placenta.

EMS reported that on September 7, 2011 at 22:21 hours he responded to a call of “maternity with complications.” Upon arrival, he reported one crew attending to the mother and another attending to the baby. The mother was observed to be lethargic, pale and bleeding from the vaginal area with a blood pressure of 90/50 and heart rate of 158…

… Respondent’s assistant (name unknown) stated that that the baby had been born at 9:15pm, the placenta had failed to deliver, Respondent “pulled out the placenta” and at least “some of it had been removed.”

The attending physician at Hospital C, documented that Patient E presented with PPH and Retained Placenta and an estimated blood loss at home of 1 liter.

… Patient E underwent a Dilatation and Curettage and Repair of deep 2nd degree perineal laceration with an estimated blood loss of 1500 ml…

The Maryland Board of Nursing suspended Muhlhan’s license for, among other things:

• Practicing without required physician backup
• Attempting high risk deliveries at home.
• Use of intramuscular oxytocin to induce labor at home.
• Attempted unsuccessful manual removal of placenta at home
• Hypoxic ishcemic encephalopathy and seizure in one newborn
• Death of the baby during an attempted home VBAC

Mulhan’s conduct is completely indefensible, but, you guessed it, homebirth advocates are nonetheless supporting her. According to the website Save Homebirth with Evelyn in Maryland:

There are several problems with the way the Board of Nursing has treated Evelyn. The first, and most severe, is the fact that they suspended her license before proof has been established. One of our rights as an American is that we are deemed innocent until proven guilty. This drastic act does not allow that right to Evelyn. The Board of Nursing has stripped Evelyn of her ability to serve women in any capacity. They did not just suspend her CNM license, they also suspended her Registered Nurse (RN) license, thus completely taking away her ability to work or make a living.

Secondly, none of these complaints came from one of Evelyn’s clients or a client’s family. The complaints were filed by hospital physicians after a client was transported to the hospital. In fact, three of the five complaints came from the same hospital…

Three of the five complaints came from one hospital? Well if that’s not a conspiracy, I don’t know what is? Just because Muhlhan sent them transports including a woman with a dead baby and ruptured uterus, and another woman with a postpartum hemorrhage during which Muhlhan attempted unsuccessfully to manually remove the placenta at home, they decided to victimize poor Evelyn.

Things are not going so well with the fund raising, however:

Our Goal Is To Raise $20,000. As of 12/01/11 we have raised $1355.00

The Maryland Board of Nursing reprimanded Muhlhan in the strongest possible terms:

… The complaints regarding her practice involve her incompetent, negligent practice during home deliveries resulting in serious complications for the mother and/or death or a poor prognosis for the infant. Her practice shows a blatant disregard for the laws and regulations governing her practice as a CRNM and a reckless disregard for the health, safety and welfare of her pregnant patients. Respondent’s practice is a danger to the public health, safety and welfare.

Homebirth leaves babies dead or brain damaged. It is indeed a danger to public health.