In December CNN published a story that received a lot of attention and approval among homebirth and natural childbirth advocates, Mom defies doctor, has baby her way. Mom, Aneka, made the decision to risk her life and the baby’s life based on the flimsiest of reasons, she watched Ricki Lake’s documentary, The Business of Being Born.

She found support for her decision from ICAN (the International Cesarean Awareness Network):

“She asked me if I could find someone who would deliver her vaginally,” remembers Bobbie Humphrey, who works with ICAN. “She started to cry because she’d heard ‘no, no, no you can’t do this’ so many times.”

But Humphrey told her yes, that she knew of a midwife who would be willing to deliver her baby at home.

Aneka and her son were lucky. They survived her risky choice, but Aneka and her on line supporters had no clue it was just a matter of luck:

“People were e-mailing Aneka saying ‘congratulations, you’re a role model,” Humphrey says.

Another woman did try to emulate her, with tragic results:

A girl who I went to college with had a baby around 10 last night & both are in critical condition. This is her 4th baby. She had 3 previous c-sections & was trying for a VBAC homebirth. Her uterus ruptured in several places & she lost a lot of blood. She is intubated & had 2 blood transfusions. She isn’t out of the woods yet, by any means. The baby was born blue & unresponsive, was resusitated, but showing signs of possible brain damage. She was flown to a different hospital than her mom. The baby is being kept in some sort of induced unconscious state currently. Please keep Lori & baby Vera in your thoughts & prayers!! Thanks.

Apparently Lori transferred to the hospital at some point during the homebirth attempt. Her sister-in-law wrote on her personal blog:

… Lori lost a lot of blood because the uterus tore in several places; the docs had to replace her blood twice over. She has been in the OR at Lehigh Valley Hospital from 10pm (1/27) til now 4:20am (1/28). When I left the hospital at 4:20am, the OR team was just finishing up. I was not able to see Lori or the baby. Right now, Lori will remain intubated for the next couple of days, and in the ICU. The doctor said she is not out of the woods, she is still critical, and has a long road to recovery.

Baby Vera is also having difficulties… Somewhere in the process of removing the baby, she lost oxygen. She was born blue and flaccid and needed resuscitative measures. She pinked up and her heart rate became strong, but she remained unresponsive and could not breathe on her own. Vera was medivaced via helicopter to Jefferson Hospital in Philadephia for a cooling process. The docs are hoping that by placing Vera’s brain and body in a slightly hyperthermic [sic] state, that her little body will reset. She is responding to pain, but her pupils are still not dilating. Vera is also considered critical.

Lori’s friend posted updates on the message board:

Lori is doing better. Her blood work, urine output, and vitals signs are strong and look good. When the nurses lighten her sedation, Lori is fighting against the breathing tube, which is a good sign (she knows it’s there)….

Vera, however, is not doing as well as the doctors wanted. She has little brain activity and her pupils remain unreactive. She is still intubated and in critical condition. They have her doing the cooling treatment and will be on it for 72 hours…

Update 1/29:
Lori is doing much better – breathing & talking on her own. She still has a long recovery, though.

The doctors are trying [cooling] treatment with baby Vera. The treatment is 3 days, then it’s just watch & wait to see what happens.

All of this leaves me with questions for the folks at ICAN who encourage women to take these life threatening risks:

Will you use Lori as a role model for VBA3C? Or will you wash your hands of her and pretend this never happened?

Update (2/3/11): According to the neonatalogists “…the MRI showed that a large amount of fluid had collected (hydrocephalus) and was putting pressure on parts of the brain, actually moving sections into different areas (herniation). The EEG showed minimal electrical activity from the cerebral hemispheres. The neurologist stated that there is some brain swelling as well as significant brain damage in a large part of her brain, but she is NOT brain dead. Vera still has some reflexes. What they believe Vera has is HIE, Hypoxic Ischemic Encephalopathy.”

Update (2/12/11): Vera died last night.

The Midwives Alliance of North America (MANA), the organization that represents homebirth midwives*, thinks it’s time to reframe the debate about homebirth safety.

According to a MANA press release issue two days ago:

We believe it is time to re-frame this conversation. Midwives and obstetricians have been debating the safety of homebirth for far too long. In North America today planned homebirth for healthy women, attended by skilled providers, with access to medical consultation when necessary, is a safe option….

In other words, as the evidence mounts that homebirth leads to preventable neonatal deaths, we should stop talking about it.

Evidently, MANA and homebirth midwives have decided to copy the tactics used by the tobacco industry to divert attention from the fact that cigarette cause preventable deaths. SourceWatch explains the tobacco industry’s attempt to reframe the debate:

The “reframe the debate” strategy consists of moving the topic of a contentious dispute onto a wholly different topic. This involves making dire predictions of a more extreme outcome, portraying the original action as dangerous, tying activists to the dangerous outcome, linking the originally-proposed action to a fear-inducing outcome …

As the Tobacco Institute explained to its members:

Our judgement, confirmed by research, was that the battle could not be waged successfully over the health issue. It was imperative, in our judgement, to shift the battleground from health to a field more distant and less volatile…

Evidently MANA has made the same calculation. As I have detailed many times in the past (So tell me again why MANA is hiding its own homebirth safety data), MANA’s own data shows that homebirth has an unacceptably high rate of neonatal death. MANA knows that “the battle [can] not be waged successfully over the health issue” of homebirth safety. Therefore they have to “reframe the conversation.”

Let’s compare the tactics used in the MANA press release with the tactics of the tobacco industry.

Choice and responsibility

MANA:

First, we must understand the bio-ethical principle of autonomy as it relates to the human right of self-determination in making health care choices. Only then can we support women in their mastery of self-determination as they navigate the complicated worlds of obstetrics and maternity care and attempt to make good decisions for themselves and their families.

Tobacco industry:

[C]reate a campaign which frames and answers this question: Does America want prohibition? Will we tolerate a puritanical wave to infringe, to restrict and possibly to eliminate personal freedoms and individual choices?

Broaden the issue

MANA:

… [W]e can no longer tolerate the abysmal maternal and child health disparities that exist for our most vulnerable women and populations of color. We have our plates full with the daunting task of improving the health status of all women and infants in the United States within a social justice framework.

Tobacco industry:

The tobacco industry typically diverts attention away from a problematic topic by broadening the issue to encompass other issues. For example, the industry broadened problem of secondhand tobacco smoke or environmental tobacco smoke into a discussion of overall indoor air quality, and moved discussion of the issue to include pollutants in the air other than tobacco smoke, such as wood smoke or automobile exhaust, or shifted the focus to the efficiency (or lack thereof) of mechanical ventilation systems.

Change the focus MANA:

… We must address the fact that certain costly obstetrical practices that are not supported by science are overused, while other beneficial, low-tech practices are overlooked. Of particular concern to the Midwives Alliance and the clients we serve is the trend of increasing rates of cesarean sections, contributing to increased rates of premature birth, low birth weight infants and rising healthcare costs, while women across the country still struggle to find providers willing to attend vaginal births after cesarean (VBACs).

Tobacco industry:

…Finally, we try to change the focus on the issues. Cigarette tax become[s] an issue of fairness and effective tax policy. Cigarette marketing is an issue of freedom of commercial speech. Environmental tobacco smoke becomes an issue of accommodation. Cigarette-related fires become an issue of prudent fire safety programs. And so on.

Clearly MANA and the tobacco industry have followed the same playbook for the same reason: to divert attention from the issue of safety.

The MANA press release concludes:

… We can no longer be diverted by the distractions of disagreements among maternity professionals. We have serious work to do that cannot wait…

But homebirth safety is NOT a distraction. It is the central issue. And the only people who “cannot wait” to confirm the fact that homebirth has an unacceptably high rate of neonatal death are homebirth midwives.

The Midwives Alliance of North America already KNOWS that homebirth increases the risk of neonatal death; their own data tells them so, and that’s why they are desperately trying to hide that data. MANA “cannot wait” because they understand that more research will only confirm that fact. They need to act now before everyone learns that homebirth kills babies.

*American midwives who hold a post high school certificate (CPMs and LMs), as opposed to American certified nurse midwives and European, Canadian and Australia midwives who have university degrees

Several days ago I wrote about the philosophy of natural childbirth advocacy and its indifference to women’s need for pain relief (Natural childbirth and the invisibility of women’s needs). To the extent that natural childbirth advocates acknowledge the existence of childbirth pain, they subscribe to the “if only” school of pain management.

The “if only” school insists that a woman would not experience childbirth as agonizing …

… if only she were more knowledgeable about childbirth.
… if she hadn’t been socialized to believe that labor is painful
… if only she had eaten right and exercised.
… if only she had better support.
… if only she hadn’t had an IV and/or electronic fetal monitoring.

In other words, the “if only” crowd believes that pain is not intrinsic to childbirth; it’s someone’s fault. But pain is intrinsic to childbirth, and to understand why, requires knowledge of the neurological basis of pain itself.

Contrary to the false dichotomy of “good” pain and “bad” pain imagined by natural childbirth, which has no basis in neurology, there are two sources of pain in childbirth, exactly the same as the two sources that exist everywhere else in the body. These two types of pain are visceral and parietal (or somatic) pain.

Here’s the technical explanation from a paper written by a certified nurse midwife:

… During the dilatation phase of labor (first stage), visceral pain predominates, with pain (nociceptive) stimuli arising from mechanical distention of the lower uterine segment and cervical dilatation… These nociceptive stimuli of the dilatation phase are predominantly transmitted to the posterior nerve root ganglia at T10 through L1. Similar to other types of visceral pain, labor pain may be progressively referred to the abdominal wall, lumbosacral region, iliac crests, gluteal areas, and thighs… As the pelvic or descent phase of labor advances (late first stage and second stage), somatic pain predominates from distention and traction on pelvic structures surrounding the vaginal vault and from distention of the pelvic floor and perineum. Sharp and generally well localized, these stimuli are transmitted via the pudendal nerve through the anterior rami of S2 through S4.

Translation:

The pain of contractions is visceral pain caused by the uterine effort to push the baby into the vagina. This visceral pain is the type of pain that comes from internal organs, exactly the same as the visceral pain of a gall bladder attack or a kidney stone. The visceral pain signals are transmitted to the spinal cord through the spinal nerves of the lower thoracic and upper lumbar vertebrae and thence to the brain.

The vaginal and perineal pain of the end of labor is parietal or somatic pain. Parietal pain is sharp and well localized. The parietal pain impulses of crowning and birth are transmitted to the spinal cord through the spinal nerves of the sacral vertebrae and thence to the brain.

An epidural blocks the visceral pain of labor by “numbing” the nerves that transmit the pain to the spinal cord. The parietal pain of labor can be eliminated by “numbing” the spinal nerves that transmit the pain or, in the case of local anesthesia, by “numbing” the nerves located where the pain begins.

The key point is that the two types of labor pain are exactly the same as the two types of pain that can occur in other parts of the body. The nerve impulses are the same, they travel to the spinal cord on similar pathways, and they are sent to the brain in exactly the same way. They can also be abolished in exactly the same way.

Therefore, to understand why the “if only” school of management is wrong, not only in their understanding of pain, but also in their claims about what can and cannot “cause” pain, it helps to apply their claims to other forms of pain.

Consider gall bladder pain, a classic form of visceral pain that occurs when the gall bladder attempts to squeeze out bile but cannot because the duct is blocked by gallstones. Would a patient in the midst of a gall bladder “attack” have less pain if only she were more knowledgeable about gall bladder attacks? If she hadn’t been socialized to believe that gall bladder attacks are painful? If only she had eaten right and exercised? If only she had better support? If only she hadn’t had an IV and/or electronic blood pressure monitoring? The answers of course are no, no, no, no and no.

And why are all the answers “no”? Because gall bladder pain arises from the contractions of the gall bladder attempting to push out a gallstone, is transmitted to the spinal nerves and thence to the brain. The pain impulses from a gall bladder attack aren’t modified by knowledge, socialization, diet and exercise, nursing support or the presence of basic medical safety measures. There’s no reason to expect that they would be modified by these factors. Similarly, there’s no reason to expect that labor pain would be modified by these factors, either.

How about parietal pain? Consider pain from a broken bone, and ask the same questions. The answers will be “no” once again and for exactly the same reason. Just like knowledge, socialization, diet and exercise, nursing support or the presence of basic medical safety measures would not be expected to modify the pain of a broken bone, they cannot be expected to modify the pain of crowning and birth, either.

So why does childbirth hurt? Because of the pain! The pain that is produced by nerve signals, transmitted to the spinal cord, and carried to the brain in exactly the same way as visceral and parietal pain from any other part of the body.

There is no scientific basis for the claims of the “if only” school of childbirth pain. It’s just another attempt to render women’s needs invisible.

One of the biggest problems in homebirth midwifery is that homebirth midwives* don’t know what they don’t know. Their background in obstetrics, science and statistics is very limited; so limited, in fact, that they have no idea how little they know compared to those who have far more education and training in these subjects.

The classic paper on this phenomenon is Unskilled and Unaware of It: How Difficulties in Recognizing One’s Own Incompetence Lead to Inflated Self-Assessments by Kruger and Dunning published in Journal of Personality and Social Psychology in 1999. The paper reports on a variety of experiments that were used to evaluate individuals’ actual performance compared to predicted performance.

For example, study subjects were given a test of basic logic:

…Participants … completed a 20-item logical reasoning test that we created using questions taken from a Law School Admissions Test (LSAT) test preparation guide. Afterward, participants … compared their “general logical reasoning ability” with that of other students from their psychology class by providing their percentile ranking. Second, they estimated how their score on the test would compare with that of their classmates, again on a percentile scale. Finally, they estimated how many test questions (out of 20) they thought they had answered correctly…

The results are displayed in the following graph:

The dark lines represent the test subjects’ rating of their logical reasoning ability and the score they predicted they would get. The dotted line represents the actual score. The graph demonstrates that the ability to correctly predict one’s score is directly related to the actual score. Those who scored poorest on the test of logic grossly overestimated their ability; those who did slightly better slightly overestimated their performance; and those who scored moderately well were accurate in predicting their own performance.

In other words, those who knew the least were also the least capable in understanding how little they knew.

The authors also found that improving the subjects knowledge of logic led to more realistic personal assessments. They divided a new group of test subjects in two. One half received a lesson in logic before the test; the other half received a lesson in an unrelated subject. Those who received the lesson in logic were much more likely to accurately predict performance on the test.

… Before receiving the training packet, these participants [in the lowest quartile] believed that their ability fell in the 55th percentile, that their performance on the test fell in the 51st percentile, and that they had answered 5.3 problems [out of 10] correctly. After training, these same participants thought their ability fell in the 44th percentile, their test in the 32nd percentile, and that they had answered only 1.0 problems correctly…

No such increase in calibration was found for bottom-quartile participants in the untrained group.

As the authors explain:

Participants scoring in the bottom quartile on a test of logic grossly overestimated their test performance — but became significantly more calibrated after their logical reasoning skills were improved. In contrast, those in the bottom quartile who did not receive this aid continued to hold the mistaken impression that they had performed just fine.

Why hadn’t the study participants realized their own deficiencies in basic logic simply by interacting over the course of their lifetime with other people who knew more basic logic?

… [S]ome tasks and settings preclude people from receiving self-correcting information that would reveal the suboptimal nature of their decisions. [And], even if people receive negative feedback, they still must come to an accurate understanding of why that failure has occurred.

That’s why homebirth midwives have no idea how little they know. Because homebirth midwives never encounter anyone in their training besides other homebirth midwives, they have no opportunity to observe that many other health professionals have a much larger knowledge base and a much greater skill set. When disasters do occur at homebirth, midwives fail to understand that they were responsible and simply dismiss tragedies with the all purpose adage that “some babies die.”

Moreover:

… [I]ncompetent individuals may be unable to take full advantage of one particular kind of feedback: social comparison. One of the ways people gain insight into their own competence is by watching the behavior of others… However, [our study] showed that incompetent individuals are unable to take full advantage of such opportunities. Compared with their more expert peers, they were less able to spot competence when they saw it, and as a consequence, were less able to learn that their ability estimates were incorrect.

This problem is greatly aggravated in homebirth midwifery because homebirth midwives are literally taught to view anyone who does things differently as objects of contempt. Doctors are supposedly greedy, incompetent and ignore scientific evidence. This attitude is best illustrated by the perjorative appellation of certified nurse midwives as “medwives.” Though CNMs have far more education and training than homebirth midwives, homebirth midwives prefer to pretend that CNMs spent that extra time being “socialized” (i.e. brainwashed) in “techno-medicine.”

The authors conclude:

… [W]e present this article as an exploration into why people tend to hold overly optimistic and miscalibrated views about themselves. We propose that those with limited knowledge in a domain suffer a dual burden: Not only do they reach mistaken conclusions and make regrettable errors, but their incompetence robs them of the ability to realize it.

Similarly, homebirth midwives hold overly optimistic views about their knowledge base and their clinical skills. Not only do they reach mistaken conclusions and make deadly errors, but their incompetence robs them of the ability to realize it.

*American midwives who hold a post high school certificate (CPMs and LMs), as opposed to American certified nurse midwives and European, Canadian and Australia midwives who have university degrees

I have often commented that the philosophy of “natural” mothering (natural childbirth, lactivism, attachment parenting) rests on fundamental assumptions that are often unrecognized and therefore unexamined. Last week I wrote about the social construction of risk within our culture and the social imperative that everyone (mothers and doctors) do everything possible to minimize risks to babies without ever considering the trade-offs that reducing specific risks imply.

But risk is not the only thing that is socially constructed within the philosophy of “natural” mothering. Women’s needs are also socially constructed; specifically, in the philosophy of natural mothering, women’s needs are rendered invisible. Natural childbirth advocacy and its approach to the issue of pain in labor is perhaps the paradigmatic example of the way in which natural mothering erases the needs of women.

Natural childbirth advocacy uses several different strategies to render women’s needs invisible. To understand how these strategies work it makes sense to start with the empirical facts that most of us agree upon:

1. Childbirth is excruciatingly painful. Indeed the pain of childbirth is so impressive that ancient cultures imagined that the only possible explanation was divine punishment of women for their transgressions.

2. Severe pain should be treated. No one would ever suggests that cancer pain be ignored or that pain from a broken bone should go untreated.

3. Medical professionals have an obligation to treat pain. Every human being is entitled to the medical treatment of pain if that’s what he or she desires.

Natural childbirth advocates employ a variety of strategies to render invisible women’s need for pain relief. The first strategy is to insist that a mother’s need for pain relief is insignificant when compared to the “risks” of epidurals. This strategy is all the more remarkable when one considers that the “risks” of epidurals are not empirical, but purely speculative. Presumably, the baby has a need and a right, to avoid any potentially harmful effects from epidurals that might be discovered as some unspecified future time. And that need (even though theoretical) trumps the mother’s need for pain relief, despite the fact pain of this magnitude would always be treated if it were from any other source.

The intellectual sophistry of such a claim is all too apparent. The natural childbirth project involves invoking risks that may not even exist and inflating both the severity and the likelihood of such risks. And it rests on the assumption that no matter how theoretical or how small these risks may be, they automatically trump a woman’s need for pain relief. A woman’s need for pain relief is therefore of no consequence and not even worthy of consideration.

Even when natural childbirth advocates concede that women might feel a need for pain relief, they employ a variety of strategies to diminish the importance of that need. These strategies involve

Blaming the woman for her own pain – if she did it “right,” childbirth would not be painful.
Blaming the woman for not using “natural” methods of pain relief – regardless of their questionable value in providing adequate relief.
Blaming the woman for not embracing the pain as an “empowering” aspect of her biological destiny.

Simply put, according to natural childbirth dogma, a woman’s pain in labor is irrelevant, of no importance compared to the baby’s need to avoid theoretical risks, and her own fault.

It is important to note that in natural childbirth philosophy, it makes no difference how small the risk to the baby might be, and it makes no difference how large the mother’s need for pain relief might be. To put that in perspective, it helps to consider another, far more trivial, example of balancing risk and need that all mothers must address.

Consider the issue of driving with a baby in the car. There is no doubt that riding in a car exposes a baby to a real risk of injury and death in a car crash, a risk whose magnitude is far greater than the theoretical risk of an epidural. And consider that the mother’s “need” to go to the grocery store is trivial, and can easily be met at another time without putting the baby in danger of injury or death in a car accident. So why aren’t natural childbirth advocates berating women for driving with infants in their cars? They consider that larger risk socially acceptable. In that case, convenience trumps whatever needs the baby might have.

The reality is that every choice has risks and benefits, and those risks and benefits must weighed against each other. But when a woman’s need for pain relief is rendered invisible, natural childbirth advocates can act as if there is no benefit to pain relief in labor and can pretend that no weighing of risks and benefits is necessary.

It is difficult to imagine any other situation in which ignoring a woman’s severe pain would be socially and ethically acceptable. But for natural childbirth advocates, a woman’s needs are invisible, and therefore merit no consideration.

No surprises here. ACOG looked over the scientific evidence once again and found that it still shows that homebirth increases the risk of neonatal death.

The ACOG practice bulletin, Committee Opinion No. 476: Planned Home Birth appears in the February issue of Obstetrics and Gynecology. The Committee notes that many of the existing scientific papers are of poor quality, and almost all are observational:

Observational studies of planned home birth often are limited by methodological problems, including small sample sizes (Wiegers 1996, Ackermann-Liebrich 1996, Davies 1996, Janssen 2002); lack of an appropriate control group (Woodcock 1995, Anderson 1995, Murphy 1998, Johnson and Daviss 2005); reliance on birth certificate data with inherent ascertainment problems (Wax Maternal and newborn morbidity by birth facility among selected United States 2006 low-risk births 2010, Pang 2002); ascertainment relying on voluntary submission of data or self-reporting (Wiegers 1996, Anderson 1995, Johnson and Daviss 2005, Lindren 2008); a limited ability to accurately distinguish between planned and unplanned home births (Pang 2002, Mori 2008); variation in the skill, training, and certification of the birth attendant (Johnson and Daviss 2005, Pang 2002, Scramm 1978); and an inability to account for and accurately attribute adverse outcomes associated with antepartum or intrapartum transfers (Ackermann-Liebrich 1996, Pang 2002, Parratt 2002).

Then they turn to the most recent Wax study (Home versus hospital birth—process and outcome 2010):

… Although perinatal mortality rates were similar among planned home births and planned hospital births, planned home births were associated with a twofold-increased risk of neonatal death. When limited to only nonanomalous newborns, the increased risk of neonatal death was even higher––almost threefold higher in planned home births. These results did not change when the investigators performed sensitivity analyses excluding older studies or poorer quality studies. No maternal deaths were reported among 10,977 planned home births. When compared with planned hospital births, planned home births are associated with fewer maternal interventions …

They emphasize that all the existing scientific studies that show that homebirth is as safe as hospital birth comes from other countries that have strict selection criteria, dedicated transport systems, and highly trained midwives.

In summary:

… Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence. Specifically, they should be informed that although the absolute risk may be low, planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth. Importantly, women should be informed that the appropriate selection of candidates for home birth; the availability of a certified nurse–midwife, certified midwife, or physician practicing within an integrated and regulated health system; ready access to consultation; and assurance of safe and timely transport to nearby hospitals are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes.

Anyone who has been following this blog will not be surprised since I’ve written about almost all of these studies and pointed out that with the exception on the recent Dutch and Canadian studies (de Jonge 2010, Janssen 2009), there are no properly done studies that show that homebirth is safe. With the exception of the most recent Dutch and Canadian studies, all the existing studies that claim to show that homebirth is safe suffer from serious methodological flaws that render their conclusions invalid.

Although the Committee does not address this issue, recent data from The Netherlands suggests that the results of the de Jonge study are also in question. There may be no difference in mortality rate of midwife attended hospital and homebirth, but obstetricians have better outcomes in hospitals, even when caring for high risk patients, putting the safety of all midwife attended births (hospital or home) in doubt.

I wish the Committee had not place such reliance on the most recent Wax study, because as I wrote when it was released, it’s not a great study. No doubt American homebirth advocates will leap on this to discredit the Committee report, but that’s merely an attempt to divert attention from the key points which are indisputable:

There is not a single study that shows that American homebirth is as safe as hospital birth. All of them suffer from serious methodological flaws, particularly the use of inappropriate control groups designed to make the homebirth outcomes look better by comparison.

The only places where homebirth might potentially be as safe as hospital birth is The Netherlands and Canada, both of which have strict eligibility criteria, dedicated transport systems and highly trained midwives. Of these three criteria, American homebirth lacks ALL of them. And, as I pointed out above, the meaning of the Dutch results are now in doubt since the mortality rates of all midwife attended births are higher than the mortality rates for physician attended hospital births.

So homebirth advocates can jump up and down about the inclusion of the Wax study, but that doesn’t change the basic facts. There is NO evidence to show that American homebirth is safe, and a great deal of evidence to suggest that it is not.

Last week I wrote about how contemporary societal beliefs about risk lead to defensive medicine.

There have always been risks, of course, but they have traditionally been viewed as outside the control of human beings. The risk society has arisen because of new beliefs that we can and (especially) that we should control every aspect of risk…

What does this have to do with defensive medicine? Consider that in our risk society we are supposed to reduce our risk to zero. How do we do that? We do that by acting to reduce risk regardless of how small the risk might be.

Defensive medicine is a direct result of our societal beliefs about risk, but doctors are not the only ones whose stance has become defensive in response. In our risk society we have come to believe that mothering itself is about managing risks. Ironically, those most obsessed with risk belong to the “natural” mothering crowd. In fact, it is hardly an exaggeration to say that “natural” mothering is really “defensive mothering” at the extreme. And natural childbirth is no exception.

Joan Wolf, in a fabulous new book entitled Is Breast Best?: Taking on the Breastfeeding Experts and the New High Stakes of Motherhood explains that in a society obsessed with risk:

… In a risk culture, when virtually everything from conception through childbirth can ostensibly be either controlled or optimized, nature becomes a beacon …

But nature, apparently, is just as obsessed with reducing risk as doctors are with reducing liability. While natural childbirth advocates claim to reject science as the primary lens through which we should view childbirth:

In natural mothering advice … the virtues of nature are filtered by science and expertise and much of what opponents of medical intervention champion is less a rejection that a selective embrace of scientific authority. Natural childbirth and parenting are mediated by classes and experts, and books are written by authors whose credentials are prominently displayed next to their their names.

The advice dispensing Sears’ family is paradigmatic examples. Father and son (William and Bob) are pediatricians and mother (Martha) is a nurse. While the Sears’ claim to disavow the belief that experts know more about parenting than parents:

The eponymous Sears Parenting Library … is itself an example of the expert culture that that infuses the discourse of total motherhood … The back cover of The Baby Book seeks to establish Sears as an authority in pediatric science. He and his wife are “the pediatrics experts to whom American parents are increasingly turning for advice and information …

So much for trusting your intuition.

Not only do Sears’ books position him as a scientific expert, he, too, is obsessed with risk. After identifying a seemingly interminable list of risks posed by various maternal behaviors:

…Sears and Sears suggest that even hypothetical risks should be avoided… The Sears state that “there is no pain-relieving drug that has ever been proven to be totally safe for mother and baby” in childbirth. But this is true, without exception, of every drug and consumer on the market; no medication has ever been shown to be completely safe for anyone…

Moreover:

Sears and Sears selectively employ science in ways that exacerbate public misunderstanding of risk. They ignore costs and trade-offs, and they hold decision making in pregnancy to an impossible standard. In embracing the notion that mothers are responsible for elimination all conceivable risks to their children, natural mothering furthers an ideology of total motherhood that is fundamentally similar to more mainstream approaches.

… Pregnancy in total motherhood literally embodies the essence of risk culture: the hyperawareneness of potential danger, the illusion of control, and the conviction that proper planning can eliminate risk…

Total motherhood is really defensive motherhood because:

[It] stipulates that mothers’ primary occupation is to predict and prevent all less-than-optimal social, emotional, cognitive and physical outcomes; that mothers are responsible for anticipating and eradication every imaginable risk to their children, regardless of the degree or severity of the risk or what the trade-offs might be; and any potential diminution in harm trumps all other considerations …

Sound familiar? It ought to, because that is the rationale for defensive medicine, the expectation that obstetricians must anticipate and eradicate every imaginable risk regardless of severity or what the trade-offs might be.

When we, as a society, become obsessed with risk, everyone is forced to behave defensively, not just doctors. That’s why solution to defensive medicine does not lie with doctors, it lies with all of us. Defensive medicine is not the only, or even the worst, manifestation of our obsession with risk. Defensive mothering is far more pervasive, entirely unrecognized, and is having a far greater impact on our children and ourselves than defensive medicine ever could.

Ordinarily I’d say, better late than never. In this case, though, all the damage has already been done.

I’m referring to the decision of Salon.com to withdraw its infamous 2005 piece written by Robert F. Kennedy, Jr. and alleging that thimerosol in vaccines had caused neurological damage in children and that a vast conspiracy had covered it up.

Why did they withdraw the article? Because it was flat out false, had been flat out false at the time it was written, represented the unsubstantiated musings of a celebrity who was in no way qualified to analyze vaccine safety, … and oh, by the way, one of their former writers has just published a book containing an entire chapter on the fact that Salon.com had broken just about every rule of professional journalism in publishing it.

Unfortunately, Salon.com continues to offer weasel words in its defense:

The piece was co-published with Rolling Stone magazine — they fact-checked it and published it in print; we posted it online. In the days after running “Deadly Immunity,” we amended the story with five corrections … that went far in undermining Kennedy’s exposé. At the time, we felt that correcting the piece — and keeping it on the site, in the spirit of transparency — was the best way to operate. But subsequent critics, including most recently, Seth Mnookin in his book “The Panic Virus,” further eroded any faith we had in the story’s value. We’ve grown to believe the best reader service is to delete the piece entirely.

They fact checked it? If by fact checking they mean making sure the spelling of all the big words was correct, perhaps they did. But if they mean checking to see whether there was any factual basis for the claims in the piece, no one did any fact checking. The entire piece was a series of false empirical claims that could easily be debunked by any vaccine expert.

Author Seth Mnookin is far more critical in the interview he did with Salon.com about his new book. He bluntly states that the media bares the bulk of the blame for creating hysteria by publishing falsehoods that, even at the time, did not withstand the most basic scrutiny.

Mnookin identifies a variety of journalistic standards that were violated with the publication of Kennedy’s article.

1. Creating false equivalence:

One is this false sense of equivalence. If there’s a disagreement, then you need to present both sides as being equally valid. You saw with the coverage of the Birther movement; it’s preposterous that that was an actual topic of debate. The fact that Lou Dobbs addressed that on his show on CNN is an embarrassment. It’s not a subject for debate just because there are some people who said it was.I do think that the media has more — we have more responsibility for this than really any other single entity… And I think it’s an absolute cop-out for reporters to say, “I’ve fulfilled my responsibility by presenting two sides.” Sometimes there aren’t two sides.

2. Letting reporters and editors who have no education, background or training on judging the validity of a scientific claim judge the validity of a scientific claim.

… You wouldn’t ask me to go write about hockey, because I don’t know anything about hockey. But if something came in over the wire about a cancer study … that assignment could end up on a general reporter’s desk. You wouldn’t ask me to cover business or the movie industry without knowing something basic about it. I don’t know how this happened, but I think there has to be some sort of movement away from, oh, like, we’re going be the first ones with this juicy story. And then in the days and weeks to come, we’ll figure out what the reality is …

3. Believing that it is acceptable to publish outlandish claims as long as you retract them later:

… It’s sort of like putting the genie back in the bottle… It’s the same thing with Obama and the Birther movement. Most outlets now certainly say that he was born in the United States. But once it’s introduced as a topic of discussion it’s really hard to un-introduce it.

There’s a final factor that Mnookin didn’t mention.

4. The willingness to publish anything uttered by a celebrity. Mnookin notes:

… If I said that, oh, I have a report that Derek Jeter’s going to quit baseball, no one would run that because it would be embarrassing. Because there’s no information to support it. If I said that I have good information that Boeing is about to buy IBM, you know, people wouldn’t run that. But for some reason when it comes to health and science, you don’t get that…

That “some reason” is the willingness to repeat any drivel uttered by a celebrity in order to grab readers. Had the vaccine piece been written by “Robert Keene, Jr.” instead of Robert Kennedy, Jr., it never would have seen the light of day. Why publish the uneducated musings and conspiracy theories of a private individual? But when a celebrity commits his or her uneducated musings and conspiracy theories to paper, media outlets fight for the privilege of publishing them.

This is not a trivial issue. Children have died and will continue to die of vaccine preventable illnesses because of the fear generated by media outlets like Salon.com who have been more concerned with page views than with the truth. As Mnookin points out, introducing outlandish conspiracy theories into mainstream media publications legitimizes them, and it is impossible to un-introduce those topics.

Salon.com offers a qualified mea culpa, but we would be better served if Salon.com promised to put journalistic protections in place. We would benefit from a commitment to avoid false equivalence. We would benefit from a commitment to have science issues covered by reporters who know something about science? We would benefit from a commitment to have science articles fact check with scientific experts, not lay people. And we would benefit from a commitment to stop recycling the bizarre conspiracy theories of celebrities.

How about it Salon?

In the wake of the controversy over Amy Chua’s new book “Battle Hymn of the Tiger Mother,” I decided it was the right time to offer my mothering philosophy to the world. Ms. Chua, a Harvard educated Yale Law Professor believes that the rest of us are frantically trying to figure out how Asian parents raise such high achieving children. She is ready to share the secret with us: She is a “Tiger Mother,” a mother who bares her teeth and growls all manner of threats, taunts and jeers at her children.

Here’s my secret: I am a “Koala Mother.” I’m warm and fuzzy and offer a safe place to escape from the pressures of the world.

According to her piece in the Wall Street Journal charmingly entitled Why Chinese Mothers Are Superior, Ms. Chua reveals:

Here are some things my daughters, Sophia and Louisa, were never allowed to do:

• attend a sleepover

• have a playdate

• be in a school play …

• watch TV or play computer games

• choose their own extracurricular activities

• get any grade less than an A …

In contrast, as a Koala Mother, I didn’t merely let my four children do all those things; I encouraged them. And it gets worse: the TV was on in our house from dawn to dusk and video games were the order of the day when homework was done.

For those who wish to be Tiger Mothers, Ms. Chua offers a few helpful examples:

The fact is that Chinese parents can do things that would seem unimaginable—even legally actionable—to Westerners. Chinese mothers can say to their daughters, “Hey fatty—lose some weight…”

Chinese parents can order their kids to get straight As. Western parents can only ask their kids to try their best. Chinese parents can say, “You’re lazy. All your classmates are getting ahead of you…”

In contrast, as a Koala Mother, I would never taunt my children (I would be ashamed of myself if I did) and I would do my utmost to protect them from taunting from others.

Ms. Chua proudly relates how “coercion works.” Describing 7 year old Lulu’s reaction to her mother’s demand that she practice piano 3 hours a day to master “The Little White Donkey,” Ms. Chua reports:

Back at the piano, Lulu made me pay. She punched, thrashed and kicked. She grabbed the music score and tore it to shreds. I taped the score back together and encased it in a plastic shield so that it could never be destroyed again. Then I hauled Lulu’s dollhouse to the car and told her I’d donate it to the Salvation Army piece by piece if she didn’t have “The Little White Donkey” perfect by the next day. When Lulu said, “I thought you were going to the Salvation Army, why are you still here?” I threatened her with no lunch, no dinner, no Christmas or Hanukkah presents, no birthday parties for two, three, four years. When she still kept playing it wrong, I told her she was purposely working herself into a frenzy because she was secretly afraid she couldn’t do it. I told her to stop being lazy, cowardly, self-indulgent and pathetic.

Here’s how I put my strategy into action:

Rather than demanding that my children achieve high grades, I pointed out that it was up to them to determine what they would make of their lives. Their father and I had made our choices: we had already finished high school, college and graduate school because it was very important to us. If it was important to them, too, they would work hard so that they could always choose what they wanted instead of being forced to accept the limitations of bad grades.

No doubt, Ms. Chua would consider me one of those Western parents who “are concerned about their children’s psyches. Chinese parents aren’t. They assume strength, not fragility, and as a result they behave very differently.”

I plead guilty! As a Koala Mother, I think that a child’s inner strength is built with support, not with taunts and jeers. I figure that the world will send each of them enough disappointments and difficulties; I want to build their inner strength so they can meet those disappointments and difficulties, not tear them down so they can start practicing their coping skills as toddlers.

What Ms. Chua does not seem to understand is my commitment to being a Koala Mother is not because I’m afraid of being a Tiger Mother. It’s because I think Tiger Mothers are self-absorbed narcissists. They have serious problems with boundary issues; apparently they think that their children are extensions of themselves, and exist to advertise the superiority of their Tiger Mothers.

I, and mothers like me, recognize that my children are independent human beings with needs and desires that might be different from mine. I had the opportunity to make my own choices and I am very happy with them. They deserve the opportunity to make their own choices and choose their own path to happiness.

Oh, one other difference between Ms. Chua and myself: we have entirely different goals. She’s aiming for children who have all the outward marks of professional success. I’m hoping for children who are happy with what they choose, regardless of whether my friends will be impressed.

It’s ironic then, that Ms. Chua’s children are not really more successful than mine. True, none of mine played at Carnegie Hall, but they’ve attended top flight universities, are going to graduate school or have a highly technical, high paying job. And the best part is their accomplishments are their own.

No, let me amend that, the best part as far as this Koala Mother is concerned when they are happy with their own choices.