Navelgazing Midwife, Barbara Herrera, continues her evolution as a clinician. She has gone from someone who had a UC (and nearly lost her child in the process), to a CPM, to a student CNM. During that time, her philosophy has evolved as well. Consider her current feelings toward those who reject the use of a midwife at homebirth (The UC Oxymoron):

I’m sure that part of it has to do with many UCer’s arrogance about their knowledge and abilities to avert complications or use wishful thinking to eliminate anything negative from happening at all. The puffed out chests, bragging that they don’t need anybody sours my desire to offer assistance – because I am “anybody.” So, if they don’t need anybody, don’t need anybody!

What’s striking to me is that Herrera recognizes that her changing views reflect her increased knowledge, but fails to understand that obstetricians’ view reflect the fact that they know more than midwives, indeed far more than CPMs who are undereducated and undertrained.

Homebirth advocates complain that obstetricians will not work with CPMs. It is ironic that they fail to see that obstetricians view CPMs in the same way that she views those who choose UC. Paraphrasing Herrera:

I’m sure that part of it has to do with many CPMs arrogance about their knowledge and abilities to avert complications or use wishful thinking to eliminate anything negative from happening at all. The puffed out chests, bragging that they don’t need an obstetrician sours an obstetricians’ desire to offer assistance.

This is not the first time that Herrera has expressed resentment of those who don’t think they need a midwife. Over 2 years ago, she wrote:

When I am hired to be someone’s midwife, I am being hired as a consultant. I am being asked to share my experience and knowledge, to utilize my skills – the ones that can save a life. As a consultant, one that differs from an interior designing consultant, I am being asked to take the lives of two people in my hands and to accept the consequences of the outcome whether that is a spritz of champagne or a cell in a prison. I’ve had a long time to adjust my considerations with my practice – and they might change again (I’d be shocked if they didn’t!). I see women as individuals, listen to their needs and concerns and if we both feel we could work together, I’m game to give it a go. If I find a woman lied to me about her medical or obstetric history, if she hides behaviors she doesn’t want me to know about or if she continually jabs at me questioning my concerns with her pregnancy (and all of these have happened in the last 2 years), I’m going to send her on her way. She is a liability I don’t need to take on… a risk to my profession and life.

She failed to see the irony that time, too.

Last week I wrote about the evidence that vitamins don’t prevent cancer. Now a new study demonstrates that the fruits and vegetables that contain those vitamins don’t prevent cancer.

The study, Fruit and Vegetable Intake and Overall Cancer Risk in the European Prospective Investigation Into Cancer and Nutrition (EPIC), by Buffetta et al. appears in the latest issue of the Journal of the National Cancer Institute. The study has two major strengths. It is large (over 400,000 people) and prospective, meaning that it followed people over time instead of depending on long term recall of dietary habits. The editors of JNCI have responsibly included a summary for the press, to be sure that the results are reported correctly:

… Paolo Boffetta, M.D., M.P.H., of the Mount Sinai School of Medicine in New York, and colleagues analyzed data from the EPIC study (European Prospective Investigation into Cancer and Nutrition), which included 142,605 men and 335,873 women recruited for the study between 1992 and 2000. The participants were from 23 centers in ten Western European countries–Denmark, France, Germany, Greece, Italy, the Netherlands, Norway, Spain,Sweden and the United Kingdom. Detailed information on their dietary habit and lifestyle variables was obtained. After a median follow-up of 8.7 years, over 30,000 participants were diagnosed with cancer.

The authors found a small inverse association between high intake of fruits and vegetables and reduced overall cancer risk. Vegetable consumption also afforded a modest benefit but was restricted to women. Heavy drinkers who ate many fruits and vegetables had a somewhat reduced risk, but only for cancers caused by smoking and alcohol.

Most importantly, the press summary explains the interpretation of the findings.

The authors caution against attributing any risk reduction to diet and they conclude that any cancer protective effect of these foods is likely to be modest, at best.

In this population, a higher intake of fruits and vegetables was also associated with other lifestyle variables, such as lower intake of alcohol, never-smoking, short duration of tobacco smoking, and higher level of physical activity, which may have contributed to a lower cancer risk,” they write.

In other words, the tiny observed benefits are more likely to be due to confounding factors than to represent any protective effect of fruits and vegetables.

In an accompanying editorial, Dr. Walter Willet, from the Department of Nutrition at the Harvard School of Public Health that the data suggesting a cancer protective effect of fruits and vegetables was never strong.

During the 1990s, enthusiasm swelled for increasing consumption of fruits and vegetables with the expectation that this would substan­tially reduce the risk of many cancers. Potential reductions as large as 50% were suggested. The National Cancer Institute’s 5-A-Day program was developed in 1991 to promote increasing the average consumption of fruits and vegetables to five or more servings per day … However, the evidence for a large preventive effect of fruits and vegetables came primarily from case–control studies, which can be readily biased by differences in recall of past diet by patients with cancer and healthy control subjects. Even more problematic, participation rates in surveys have fallen sharply over the past 50 years so that those who agree to be interviewed as control subjects are likely to overrepre­sent health conscience persons who smoke less, exercise more, and eat more fruits and vegetables compared with those who do not participate…

Yet despite the weak evidence, lay people and professionals alike embraced the conclusions enthusiastically. Why? As a society we have a disturbing tendency to promote simple (and often unproven) answers to complex issues. It would be wonderful if cancer, a complex and multifaceted disease, could be prevented by eating fruits and vegetables. Such a simple answer sounds (and is) too good to be true, and should have been greeted with skepticism instead of uncritical acceptance.

Within the scientific community, it has been known for quite some time that the protective effect of fruits and vegetables had been vastly overstated. As Willet explains:

… In the late 1990s, the results of large prospec­tive cohort studies of diet and cancer began to accrue, and these did not confirm the strong inverse associations found in most case–control studies. Furthermore, a series of analyses that pooled the data from prospective studies for specific cancer sites confirmed the weak and non-statistically significant associations. In a comprehensive 2007 review, these findings led to the reversal of conclusions for strong benefits of fruits and vegetables for many cancer sites that had been considered convincing or probable in a similar earlier review 10 years before.

That message has not reached the general public and even many healthcare providers.

Fortunately, there was no harm done, and there was possibly a benefit in a decrease in cardiovascular disease as a result. Nonetheless, it is yet another example of a disturbing trend in preventive medicine, the tendency to issue public health recommendations on the basis of weak data. As a result, public health recommendations are often modified or even withdrawn after only a few short years, leading to distrust of science in general and the medical profession in particular.

Morgan McLaughlin McFarland, in a guest post at Bring Birth Home entitled Brave Has Nothing to Do With It, helpfully illustrates the self aggrandizing ignorance that is the hallmark of homebirth advocacy. She is annoyed:

“When hearing the news that I had my last baby at home and am planning to have this one at home as well, the first response from most people is, “You’re so brave.”

This has to be one of the most irritating things that people say to homebirthers. The implication is that birth is dangerous and that we are willing to take on a tremendous risk to do it anywhere but a hospital.

It negates the research and planning that we’ve done to come to this decision. It makes the choice about balls, not brains. After all, homebirth is “dangerous.” Hospital birth is “safe.” Therefore, it must be bravado alone that would lead a woman to choosing such an option. Right?”

Research? Now that’s a hoot. In the homebirth community, what passes for “research” is being impressed by the bibliography salad cited by professional homebirth advocates who don’t understand (and probably have not even read) the papers that they cite.

Let’s see what McLaughlin has “learned” from her “research.”

“Over 30% of women in the US have cesarean sections, while overwhelming research has led the World Health Organization to set an ideal standard rate of cesarean sections at 10-12%, with 15% being the rate where more harm is being done instead of good.”

Hey, Morgan, you just made that up. Marden Wagner, then at the WHO, pulled the 15% number out of thin air. There has been NO research, none, zip, zero, nada, to support the 15% recommendation, a point that Wagner himself has publicly acknowledged.”

“Kenneth C Johnson and Betty-Anne Daviss’s Outcomes of planned home births with certified professional midwives: large prospective study in North America, BMJ 2005;330:1416 (18 June), found that the outcomes of planned homebirths for low risk mothers were the same as the outcomes of planned hospital births for low risk mothers, with a significantly lower incident of interventions in the homebirth group.”

See what happens when you don’t read and analyze the study? You don’t know what it actually shows. The Johnson and Daviss study actually shows that homebirth with a CPM has nearly triple the rate of neonatal mortality of low risk hospital birth. Guess you didn’t pick up the bait and switch. J & D compared low risk homebirths to high risk hospital births. Funny what you learn when you do real research.

“The Netherlands, where 36% of babies are born at home, has lower maternal and neonatal mortality rates than the US.”

The Netherlands has the highest perinatal mortality rate in Europe! The US has a lower perinatal mortality rate than Denmark, the UK and the Netherlands. By the way, according to the World Health Organization, the correct statistic for international comparisons is perinatal mortality (neonatal mortality plus late stillbirths). That’s because countries like The Netherlands like to boost their international rankings in neonatal mortality by pretending that premature babies born alive are stillbirths and not live births. I guess you didn’t learn that basic fact in your “research.”

“Call me stubborn, because I wasn’t willing to accept out of hand the culturally held belief that hospitals are safer.”

No, I’d call you ignorant, so ignorant that you actually think you know what you are talking about. You’ve done no research. You’ve read no papers. You lack even the most basic understanding of science and statistics. You don’t even realize that virtually everything you’ve written is factually false.

“Call me an idealist, because I believe that birth can be a positive, safe, and empowering experience for child and mother.”

No, once again I’d call you ignorant. Birth is inherently dangerous. It is and has always been a leading cause of death of young women and babies in every time, place and culture. “Believing” birth is safe just shows that you don’t know much about birth.

“Call me a nonconformist, because I choose to birth at home in defiance of a powerful technocratic system.”

No, I’d call you ignorant, and self aggrandizing to boot. Only a fool would proudly risk her baby’s life to “defy the system.”

“But brave? Don’t call me brave. “Brave” has nothing to do with it.”

That’s right. Brave has absolutely nothing to do with it. It’s all about ignorance.

Yet another paper on the benefits of breastfeeding (real and purported) was released today (Bartick and Reinhold, The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis) in the ongoing, well meaning but basically futile effort to “educate” (i.e. bully) women into higher rates of exclusive breastfeeding. Using highly fanciful methods, Bartick and Reinhold “estimate” that the US could save 900 infant lives and $13 billion if 90% of US women breastfed. These numbers are grossly misleading since not even a single US infant death (let alone 900 per year) has ever been attributed to not breastfeeding and since the purported savings are primarily the “lost wages” of the 900 dead infants.

But let’s leave aside for the moment, the fact that the figures on which Bartick and Reinhold based their claims are profoundly suspect. Let’s look at their potential motivation.

Breastfeeding advocates like to pretend that women stop breastfeeding because of lack of education, because hospitals give out formula, because of lack of professional support, because of lack of peer support, etc. etc. etc. All this pretending reflects the profound unwillingness of breastfeeding advocates to avoid addressing the real reasons that women stop breastfeeding or fail to start in the first place. The dirty little secret about breastfeeding is that starting is hard, painful, frustrating and inconvenient. And continuing breastfeeding is hard, sometimes painful, and incredibly inconvenient especially for women who work, which in 2010 is most women.

Any article such as this virtually requires the author to demonstrate her bona fides, so let me get that out of the way. I have four children, I breastfed them all nearly exclusively until they weaned themselves. I breastfed even when I was working up to 70 hours a week and was on call every 3rd night. I always had access to an office that could be locked, a state of the art breast pump, and a fair degree of control over my own schedule. I never contemplated doing anything else, but that doesn’t change the fact that it was hard, painful in the early stages and incredibly inconvenient. I did it despite the difficulties.

Breastfeeding advocates insist on eliding or ignoring these difficulties. And because they insist on ignoring the experiences of women, their well meaning attempts at encouraging breastfeeding are almost complete failures. Education efforts, counseling efforts and banning of formula gift bags have made little or no difference in breastfeeding rates. Bartick and Reinhold’s latest paper on the purported economic benefits of breastfeeding, even if true (and there is a great deal of extrapolation that is probably not true) is destined to have an equally negligible effect.

I don’t really understand why breastfeeding activists refuse to acknowledge the reality of breastfeeding. They prefer to sugarcoat it with little maxims like “breast milk is always available,” breast milk is always the perfect temperature,” and “breast feeding saves money.” Those statements are true, but they ignore the very real challenges in initiating and maintaining breastfeeding.

Perhaps breastfeeding activists fear that women will not attempt breastfeeding if they are informed honestly about the difficulties. Yet it appears that the opposite is true. By not acknowledging these difficulties up front, breast feeding activists set women up for failure, when those women encounter pain, frustration and inconvenience.

Breastfeeding is a learned behavior. It is not instinctual on the part of the mother and although a baby has the instinct to suckle, latching on properly and actually getting milk requires practice. A new mother and a new baby may get frustrated very quickly when things do not proceed smoothly.

New mothers are often emotionally labile, due to the effect of hormones. A baby screaming desperately in hunger (and all babies begin to screaming desperately within seconds of realizing they are hungry) can upset even an experienced mother. It’s much worse for a new and inexperienced mother who can easily become frantic to satisfy the baby, fearing that the baby is starving. Prior to the advent of formula, there was no choice but to stick with the first inexperienced attempts. Now, with formula at hand and able to satisfy an infant in seconds, it may seem pointless or even cruel (not to mention harrowing to the mother) to force a baby to figure out breastfeeding.

Initiating breastfeeding is often painful. Cracked and bleeding nipples are every bit as unpleasant as it sounds. Countless new mothers tell stories of bursting into tears whenever the baby starts to cry, in anticipation of the pain of nursing. For most women, the pain disappears over time, but it can take days or even weeks. Breastfeeding advocates like to blame women themselves for their pain, insisting that they are positioning the baby in the wrong way. The truth is that women can do everything right, and still have pain. It simply has to be ignored until it goes away and it is hardly surprising that some women do not want to wait that long.

Maintaining breastfeeding while working is incredibly difficult. During the typical work day, a woman may need to pump twice or more, each session taking 20-30 minutes and requiring a clean and private place to pump, a breast pump, and a refrigerator to store the milk. Professional women may be able to assemble these resources, but the average working woman has neither the facilities, nor the time to pump at work.

The demographics of breastfeeding reflect the fact that it is difficult. Breastfeeding is associated with higher levels of maternal education and higher income levels. Successful and long term breastfeeding require a willingness to delay personal gratification, and a willingness to shoulder burdens in exchange for long term benefits. Those traits are closely associated with higher levels of education and professional success. Economic success also makes it easier to continue breastfeeding because women don’t have to work, enjoy extended maternity leaves, have private space at the workplace in which to pump and can afford high quality equipment.

Should we encourage breastfeeding? Of course, we should, but we should not forget that the health benefits are relatively small and the difficulties can be large. We should stop spending money on trying to convince women to breastfeed, since most efforts are ineffective. Instead, we should devote smaller sums to providing counseling to women who truly want to breastfeed and leave everyone else alone.

Everyone agrees that the current C-section rate, at 33%, is a national scandal. How has it reached this level?

Obstetricians have been desperately trying to explain how liability concerns are driving the rising C-section rate, yet they are consistently ignored. That’s rather surprising since obstetricians perform the C-sections and have much greater insight into their motivations than anyone else. But everyone from insurance company executives to health policy experts to “natural” childbirth advocates disparage and ignore doctors’ explanations. How do they justify ignoring the very people whose behavior they wish to change?

Law professor Sandra Johnson offers insights into doctors’ concerns and how they are ignored in, of all places, a law review article entitled, Regulating Physician Behavior: Taking Doctors’ “Bad Law” Claims Seriously.

Doctors frequently claim that the very law intended to improve the lot of their patients is instead making the doctors provide poor care. These “bad law” claims are levied against malpractice litigation that makes doctors practice “defensive medicine”; … against antitrust laws that prevent doctors from organizing themselves in ways that would produce more cost-effective and accessible care; and against regulations that impede important medical research. These “bad law” claims assert that the law’s effort to promote patient health and well-being has actually caused significant harm.

And why have these concerns been ignored?

Medicine’s complaints … [have come] to be characterized as the work of a self serving guild, rather than a profession motivated by altruism and armed with expertise, or at least as the work of the recalcitrant “bad apples” who continued to resist improvements that the more enlightened among them embraced. These narratives marginalized physicians’ … claims and diminished them as a source of legitimate information about the effectiveness of reform efforts.

Rather than addressing the substance of doctors’ arguments, experts and lay people have denied that there the complaints are legitimate, ascribing them to greed and self interest. Yet in the case of medical liability, as in other areas of medical “reform,” doctors are often right.

What if we take doctors’ claims seriously? What can we learn about the impact of liability concerns on medical practices including Cesarean sections?

Professor Johnson explains that doctors’ liability concerns are not simply ignored; even when they are directly addressed, they are often dismissed as irrelevant by those who don’t or won’t understand their impact on individual practitioners. She identifies a number of these dismissive behaviors.

All’s not well that ends well

Policy experts and lay people alike often point to the fact that physicians win most malpractice suits as evidence that doctors shouldn’t worry about being sued. But as Prof. Johnson notes:

The enforcement process itself [in this case, the lawsuit] also imposes significant penalties in the course of identifying violators. These penalties are distinct from formal penalties levied after a conclusive finding that a violation has occurred. These “penalties of the process” exert their own deterrent effect. When substantial, they will produce avoidance behaviors on the part of those who might fall within the investigative net even though the likelihood that they will be subject to formal sanctions is nil or close to it.

In other words, the risk of being sued has a deterrent effect, regardless of whether the doctor wins or loses. And who would know better than the doctors themselves?

The deterrence effect of these informal penalties may produce results that actually undermine the goals of the formal legal requirements. Yet, they are all but invisible—they make no appearance in the formal description of the standards and procedures incorporated in the law. The best information available concerning the operation of this shadow system of enforcement comes from the people who experience it, those doctors who claim that there is “bad law” causing them to avoid doing the right thing.

The interminacy of law

Lay people in particular like to claim that if the doctor “does the right thing,” he or she has nothing to worry about. That is startlingly naive view.

… It is hardly ever the case that lawyers can tell doctors: “I assure you that you have nothing to be concerned about … You are safe.” … So, instead, what doctors often hear lawyers say is: “Well, anyone with a filing fee can sue you, but they are not going to win.” This consolation … has to ring hollow to anyone who has been the defendant in any suit, even one that is eventually dismissed. Instead of reassurance, one could understand that this phrase would be heard as confirmation of the unpredictability of the legal hammer.

Asymmetrical legal risk

At times, legal risk is lined up entirely on one side as the doctor looks at the risks of particular decisions… [W]hen we began our work on pain management in 1995, only the doctor who prescribed opioids for his patients in pain faced investigation, sanctions, and liability claims. The doctor who used the less effective medications and neglected their patient’s pain faced no legal risk at all.

The same asymmetrical risk applies to C-sections. An obstetrician who fails to perform a C-section can be accused of negligence if there is anything wrong with the baby. An obstetrician who performs a C-section, even one that is not medical necessary, faces no legal risk at all.

Professor Johnson’s most important message is that it is time to start taking physician liability concerns seriously instead of dismissing such complaints are motivated by greed and self interest:

[We] must accept that well-intentioned regulatory standards and enforcement systems can have negative outcomes as physicians react, and patients suffer as a result. Taking physicians’ “bad law” complaints seriously brings physician behavior to the table as a credible and legitimate factor in evaluating the performance of the law… Taking “bad law” claims seriously appreciates that the behavior-inducing effects of the enforcement effort may thwart the goals of the regulation itself.

Ignore obstetricians liability concerns and the C-section rate will continue to rise.

Among believers in alternative health, it is an article of faith that vitamin supplements prevent all manner of serious diseases including cancer. Yet the reality is almost exactly the opposite. According to Kristal and Lippman, writing in the Journal of the National Cancer Institute (Nutritional Prevention of Cancer: New Directions for an Increasingly Complex Challenge):

The prospects for cancer prevention through micronutrient supplementation have never looked worse. Several large, randomized cancer prevention trials have recently reported no reduced risk from micronutrient supplementation, and [there is] a growing body of evidence that micronutrient supplementation may be harmful…

The authors are commenting on a paper that appears in the same issue of JNCI that investigated whether folate supplementation decreased the risk of precancerous growths in the colon. Folate did not decrease the risk; it increased it by 67%. Further analysis revealed that folate supplementation increased the risk of prostate cancer by 167%.

The authors note:

… Among studies addressing micronutrient supplementation for the prevention of cancer, only a single randomized trial, testing 1200 mg of calcium for preventing the recurrence of colorectal polyps, has reported a statistically significant and positive result for its primary cancer outcome, whereas large trials testing supplementation with multivitamins, folate, selenium, β-carotene, and vitamins E, C, D, B 6 , and B 12 have found no benefits.

In fact:

… Even clinical trials designed to test agents that were found to reduce cancer risk in secondary analyses of previous trials, such as vitamin E and selenium for prevention of prostate cancer, have failed to find benefit from supplementation. The harmful effects of β-carotene supplementation in heavy smokers are well established, and it now appears that folate supplementation may increase cancer risk as well…

The scientific rationale for testing vitamin supplements for cancer prevention was sound. A variety of studies have shown that people who don’t have cancer have higher levels of certain micronutrients. Unfortunately, the assumption that these vitamins and minerals prevent cancer was unjustified.

… the notion that some is good and therefore more is better has been proven wrong; it is more likely that for any given micronutrient, there is an optimal range of intake.

That’s not surprising, considering how vitamins and minerals function within the body. Micronutrients are like nails in a house. Without enough nails to hold the various parts together, a house will fall apart. However, once the optimal number of nails has been reached, adding more will not increase the stability of the house and in large amounts, might even decrease stability.

That explains why vitamin supplements fail to prevent cancer. How would supplements act to cause cancer?

… using the folate supplementation trial as an example, it is not unreasonable to assume that optimal levels of folate are associated with more fidelity in DNA replication and thus a lower risk of spontaneous mutations, but high folate may also support more rapid cell growth and promote carcinogenesis in previously initiated cells.

Another possibility is that large quantities of specific vitamins or minerals may be consumed by particular types of cancer. In that case, low levels of that vitamin or mineral in cancer patients reflect the fact that the cancer needs the micronutrient. The level has dropped not because high levels of the vitamin or mineral prevent cancer, but because the cancer has used up what is available. Far from preventing cancer, supplements might actually feed the cancer and promote rapid growth.

Whatever the reason, it is clear that supplements do not represent the next frontier in cancer prevention. As the authors acknowledge:

… It is safe to conclude that cancer prevention is not going to be as simple as recommending high-dose micronutrient supplements for middle-aged and older adults.

In fact, the opposite may turn out to be true. Vitamin and mineral supplements may promote cancer growth.

The National Center for Health Statistics released a new report today, Recent Trends in Cesarean Delivery in the United States. The report is most notable for a startling statistic; the C-section rate has reached the astronomical level of 32%, an increase of more than 50% since 1996. This is disturbing news.

As the authors explain:

… Although there are often clear clinical indications for a cesarean delivery, the short- and long-term benefits and risks for both mother and infant have been the subject of intense debate for over 25 years. Cesarean delivery involves major abdominal surgery, and is associated with higher rates of surgical complications and maternal rehospitalization, as well as with complications requiring neonatal intensive care unit admission . In addition to health and safety risks for mothers and newborns, hospital charges for a cesarean delivery are almost double those for a vaginal delivery, imposing significant costs.

It’s not surprising news, though, since it merely a continuation of a worrisome trend. As the graph demonstrates:

Why is the C-section rating sky high? The pervasive nature of the increase may hold some clues. The increase has been remarkably consistent across all possible variables. The C-section rate increased among all races. It increased in all maternal age groups. It increased at every gestational age, and it increased in all 50 states. The global nature of the increase suggests that it is due to a global factor, rather than the increase in a particular diagnosis a dramatic change in specific risk factors. Like many obstetricians, I suspect that the rising C-section rate is driven by liability concerns.

It’s true that there is no correlation between numbers of lawsuits and the C-section rate. In addition, there is no correlation between the size of monetary awards and the C-section rate. There is a correlation between malpractice premiums and the C-section rate, but the association is not dramatic. So how could the C-section rate be tied to liability concerns?

The assumption behind searching for a correlation between C-section rate and malpractice lawsuits or monetary awards is that as the rate or payout of lawsuits rises, obstetricians will be reminded that they are at risk of being sued. However, if every obstetrician expects to be sued, the increasing rate of suits or payouts will be irrelevant. At this point, every obstetrician expects to be sued at least once in a professional lifetime.

According to Victoria Green, MD, JD author of the chapter Liability in Obstetrics and Gynecology in the textbook Legal Medicine:

Nearly 77% of obstetrician/gynecologists have been sued at least once in their career and almost half have been sued three or more times. Moreover, virtually one-third of residents will be sued during their residency. Fear of malpractice, in general, may cause physicians to order more tests than medically necessary, refer patients to specialists, and suggest invasive procedures to confirm diagnoses more often than needed. Nearly 40% may prescribe more medications than medically necessary due to concerns of legal liability. The public has responded by escalating the “punishment” associated with malpractice claims where multimillion-dollar jury awards are commonplace.

When obstetricians expect to be sued, it no longer matters how many other suits are filed, how high the monetary judgments are, or even whether malpractice premiums are rising. The only consideration when a lawsuit is inevitable is how to successfully defend oneself.

Consider the most common reasons for an obstetrics lawsuit. The paper Liability in High Risk Obstetrics explains the most common causes. Although the paper concentrates on high risk obstetrics (perinatology), the results appear to be generalizable to obstetrics as a whole. According to the paper’s author James L. Schwayder, MD, JD, obstetric lawsuits center on errors of omission or commission. The most common alleged errors are:

1. Errors or omission in antenatal screening and diagnosis
2. Errors in ultrasound diagnosis
3. The neurologically impaired infant
4. Neonatal encephalopathy
5. Stillborn or neonatal death
6. Shoulder dystocia, with either brachial plexus injury or hypoxic injury
7. Vaginal birth after cesarean section
8. Operative vaginal delivery
9. Training programs (Resident supervision markedly impacts litigation exposure. Increased used of nurse midwives and nurse practitioners may increase ones liability exposure.)

Of the 9 most common reasons for obstetric malpractice suits, 6 (#3-#8) allege failure to perform a C-section or failure to perform a C-section sooner. In other words, performing a C-section when there is any doubt about the baby’s health, or even before there is any doubt, will virtually eliminate the chance of being sued successfully in connection with the delivery; it might even make a lawsuit less likely if the plaintiff cannot argue that a C-section should have been performed.

Most of these potential complications are equally distributed across maternal age, maternal race, gestational age, and state of residence, leading to a rising C-section rate across all demographics. The skyrocketing rate is being driven by an attempt to defend or potentially avoid lawsuits, since the majority of lawsuits allege failure to perform a C-section or to perform a C-section sooner. An ever increasing C-section rate is the inevitable result.

The C-section rate is skyrocketing primarily for non-medical reasons. While doctors blame the tort system as the proximate cause, the fundamental cause rests with patients, not lawyers or insurance companies. The fundamental cause is an inability to tolerate any risk to a newborn. In the current legal climate, there is no possible justification for not doing a C-section, regardless of how tiny the risk posed by vaginal delivery may be. Unless and until people stop penalizing doctors for not doing C-sections, they will continue to do them in ever increasing numbers. They really have no choice. You cannot say to obstetricians, “Give me a perfect baby or I will sue you for failure to perform a C-section” and then express shock and dismay that obstetricians will perform C-sections in order to guarantee that you will have a perfect baby.

The sky high C-section rate all too predictable result of parental expectations. As long as parents continue to sue for failure to perform a C-section, the C-section rate will continue to rise.

A consortium of chiropractors, herbalists and cancer quacks has petitioned the Federal government for creation of a National Center for Health and Wishful Thinking (NCHWT). The consortium believes that both “complementary medicine” and “integrative medicine” do not reflect the reality of alternative health. A spokeswoman for the consortium, Ima Frawde, explained that those descriptions do not accurately reflect the fundamental premise of alternative health, which is wishful thinking. According to the Ms. Frawde:

We don’t merely believe in a mind-body connection. We are committed to the principle that health is determined by specific beliefs. Indeed, we feel strongly that the right beliefs can keep you healthy and the wrong beliefs can make you sick.

The consortium has published a working paper on what the National Center for Health and Wishful Thinking might look like, including plans for 6 specific departments. The following excerpts explain the departments.

Blame the Victim

A founding principle of the NCHWT is that anyone who is sick has brought it on themselves. They should have eaten better, exercised more, taken supplements and thought positive thoughts. Virtually all cases of cancer and heart disease are caused by the victim, who fully deserves the consequences including severe disability and death.

The Blame the Victim division will explore the ethical ramifications of withdrawing care from patients in order to divert the resulting savings to buy more preventive herbs and supplements for everyone else.

The “Nanny State” Department

This is the research arm of the NCHWT, though no actual research will be done. That’s because all preventive care is good, and it is a waste of money to bother proving it. The “Nanny State” Department is charged with the promulgation and enforcement of laws determining just what foods are allowed and prohibited. Building on the groundbreaking ordinances in New York City, the department will expand far beyond restrictions on trans-fats and salt. Since all disease is determined by what people eat, some substances will be banned and others promoted. To ensure enforcement, stores and restaurants will be stripped of any products that do not receive the “Nanny State” Seal of Approval.

Childbirth Affirmations

Good health begins at birth. The bedrock principle of the Department of Childbirth Affirmations is that the key to health is for the mother to be empowered by her birth experience. Neonatal mortality and morbidity are sterile concepts and cannot capture the emotional significance of birth; therefore, such data will no longer be collected.

All births will be homebirths and only those with the least amount of education training will be allowed to attend births. The full transition to Certified Professional Midwives (who proudly have less education and training than any midwives in the industrialized world) must be completed within 5 years. In the meantime, any provider accused of “birth rape” will be sentence to death; no trial is necessary.

Vaccine Rejection

It’s not merely physical health that begins in infancy, it is mental health as well. Since everyone knows that vaccines cause autism, vaccines will henceforth be banned. Moreover, closer monitoring of autism incidence will be funded by diverting money from previous efforts to track child mortality. Since infectious childhood diseases have disappeared spontaneously, there is no reason to anticipate that any children will die.

Mental Illness as a Social Construct

Obviously, mental illness is a category created to marginalize those challenge the norms of society and think outside the box. In recognition of the extreme creativity of those previously deemed “mentally ill” (e.g. Vincent Van Gogh), the use of psychotropic medications will henceforth be banned. Implementation will start by criminalizing the use of stimulant medications for ADHD since everyone knows that ADHD doesn’t exist. It is merely a ruse used by upper middle class parents to turn B students into A students and simultaneously destroy their souls.

Department of Lying

It is axiomatic that the placebo effect helps more people with fewer side effects than any other treatments. Therefore, all future disease treatments will invoke the placebo effect by substituting any active ingredients with sugar. Since lying is an integral part of the placebo effect (i.e. patients need to be convinced by the doctor that the inactive medication will be effective) requirements for informed consent will be modified to emphasize that patients should not be given accurate information about their care.

Spokeswoman Ima Frawde cautions that the working paper represents only the most basic structure of the National Center for Health and Wishful Thinking. Further elaboration may yield more departments, greater contempt for victims and new methods of tricking patients. The consortium estimates that $1 trillion dollars should be diverted from conventional healthcare to the NCHWT, and more if any actual research is contemplated in the future. Close financial relationships between supplement manufacturers and the Center are contemplated to defray any additional costs.

As Ms. Frawde proudly points out:

The National Center for Health and Wishful Thinking will embody the latest advances in health. Knocking on wood or prayer may have been acceptable to previous generations, but the healthcare strategy of wishful thinking has advanced from those primitive methods. The cornerstone of future efforts will be the placebo effect, dietary restrictions and supplements. We estimate that by 2025, the US death rate will have dropped to zero; however, since our plans include ending actual monitoring of deaths we may unwittingly achieve our goal even sooner.

In breathless language, the human rights organization Amnesty International urges the US to confront its “shocking maternal mortality rate.” Entitled Deadly Delivery: The Maternal Healthcare Crisis in the USA, the Amnesty report lays its indictment:

The total amount spent on health care in the USA is greater than in any other country in the world. Hospitalization related to pregnancy and childbirth costs some US$86 billion a year; the highest hospitalization costs of any area of medicine. Despite this, women in the USA have a greater lifetime risk of dying of pregnancy-related complications than women in 40 other countries… More than two women die every day in the USA from pregnancy-related causes…

Amnesty International is sure that this increase in maternal mortality is due to lack of access to medical care.

The US government’s failure to ensure that women have guaranteed lifelong access to quality health care, including reproductive health services, has a significant impact on the likelihood of having a healthy pregnancy and delivery.

“Natural” childbirth advocates are sure that the rising rate of C-sections and other interventions is contributing to the rising maternal mortality rate. Amnesty International appears to agree, citing a “lack of information and autonomy” as the cause.

Both decreased access and increased interventions are plausible causes of increased maternal mortality. However, it is far from clear that maternal mortality is even rising, let alone that it is rising because of decreased access to care or increases in the C-section rate or other interventions. A careful review of the data suggests that changes in the way that maternal mortality is assessed may be leading to a spurious “increase” in maternal mortality. Moreover, a detailed analysis of the causes of maternal mortality casts serious doubt on either access or interventions as the cause of any rise.

In the last two decades, there has been growing awareness that maternal mortality is under-reported. Vigorous efforts have been made to correct that problem, by both increasing surveillance and expanding categories included within maternal mortality. The CDC report Maternal Mortality and Related Concepts (2007) explains these changes:

In 1999, the coding guidelines used in the United States were expanded to cover additional categories … Furthermore, if only indirect maternal causes of death (i.e., a previously existing disease or a disease that developed during pregnancy that was not due to direct obstetric causes but was aggravated by physiologic effects of pregnancy) were reported in Part I and pregnancy was reported in either Part I or II, the death was classified as a maternal death. [Previously] the pregnancy had to be reported in Part I for the death from indirect causes to be considered a maternal death.

Along with the new definitions, the [new coding guidelines] introduced new details and categories in the cause-of-death titles associated with pregnancy, childbirth, and the puerperium…

Furthermore, in 2003, the US Standard Certificate of Death was revised to ask explicitly whether any female death was associated with pregnancy, instead of relying on the person filling out the form to voluntarily provide that information.

The results of these changes are captured by the following graph.

It is clear that the 1999 and 2003 changes in reporting of maternal mortality resulted in large “increases” that are not increases at all. They reflect the more accurate measurement of maternal mortality just as they were designed to do.

Yet some of the increase may be real. What about possible causes?

Curiously, since Amnesty International bases its entire report on the claim that decreased access to healthcare has led to increased maternal mortality, the report contains no evidence that there has been a decrease in access to maternity services. While millions of people lack health insurance, almost all states provide public health insurance for the duration of pregnancy in any woman who needs it. Indeed, 99+% of births take place in hospitals, so there is certainly no decrease in access to hospital care.

If decreased access to healthcare were responsible for an increase in maternal mortality, we would expect that the increase would be spread evenly among all possible causes of maternal mortality, but that’s not what we find. The following chart shows maternal death rates from pre-eclampsia/eclampsia, hemorrhage, embolism (the three most common causes of maternal death) as well as other direct causes (all other obstetric complications) and indirect causes (from other medical conditions).

As the graph shows, the purported increase in maternal mortality was not spread evenly across all categories. Indeed, the most common cause of maternal mortality remained flat. In contrast, the categories that were expanded in the new reporting guidelines were responsible for almost all of the purported increase. This suggests that the “increase” reflects more comprehensive reporting, not an actual increase in maternal mortality.

What about an association between the rising C-section rate and rising maternal mortality? A graph comparing the maternal mortality rate and the C-section rate certainly shows a correlation.

But correlation is not causation. If the rising C-section rate were leading to an increased maternal mortality rate, we would expect to see C-section complications, such as hemorrhage and embolism increasing disproportionately. But that’s not what we see. As the following graph makes clear, both hemorrhage and embolism death rates did not change their contributions to overall maternal mortality.

The fact that hemorrhage and embolism were flat casts doubt on the idea that the increasing C-section rate is leading to increasing maternal mortality. Moreover, the C-section rate rose from 2005 to 2006, but the maternal mortality rate actually dropped.

So what can we conclude about the observed rise in maternal mortality? First, we can see that the 1999 coding revision and the 2003 birth certificate revision captured more maternal deaths just as they were designed to do. Those increases almost certainly reflecting changes in reporting and not increases in maternal mortality. Together they account for 80% of the observed increase since 1998 (5/100,000 out of a total change of 6.2/100,000). With that in mind, the Amnesty International report can be described as overwrought, to say the least.

And to the extent that there has been a real increase, is decreased access or the increased C-section rate the causes of this increase? That seems unlikely since the increase was not distributed evenly among all causes (as would be expected if decreased access were to blame) nor is the increase predominantly distributed among common C-section complications (if the increased C-section rate were to blame).

Despite the rhetoric of Amnesty International, it is unclear whether we are experiencing a crisis of any kind, let alone a “shocking” maternal mortality rate.