Homebirth advocates often argue that homebirth costs less than hospital birth, but a new study from The Netherlands reveals that homebirth does not save money. Even the authors were surprised by the results.

The study is Cost Analysis of the Dutch Obstetric System: low-risk nulliparous women preferring home or short-stay hospital birth – a prospective non-randomised controlled study. It is worth reading merely for the update on the Dutch system of homebirth. It differs in important ways from the perceptions of American homebirth advocates regarding the Dutch system. The homebirth rate is less than 30% and falling and transfer rates are extraordinarily high:

… [T]he organisation of the Dutch obstetric system is unique, with a high percentage of home births (about 29% of all pregnant women) and a low rate of medical interventions (the rate of Caesarean sections is about 15%)… Overall, the home birth rate has decreased during the last ten years (from 35% of all births in 1997-2000 to 29% in 2005-2008). For nulliparae, the home birth rate is much lower, namely 18% in 2006. There is a high referral rate during pregnancy (45% of all nulliparae in primary care) and delivery (43% of all nulliparae who started delivery in primary care)…

Rather than being a paradise of perfect obstetric outcomes, the system has been plagued with poorer than expected results:

The Dutch obstetric system has received a great deal of attention in the literature. However, the system has increasingly come under pressure since the national perinatal mortality rate (between 22 weeks of pregnancy and 7 days postpartum) was shown to be one of the highest in Europe (10‰ in 2004)…

The study is notable for the comprehensive view of obstetric costs. As the authors explain:

Several studies have examined the economic implications of home births or short-stay hospital births in comparison with a hospital birth. However, these studies were performed outside the Netherlands… Furthermore, some of these studies had a very limited time frame, not looking at the costs from an early stage of pregnancy until a fixed period after delivery. These studies also did not calculate the societal costs of giving birth, meaning that … [the] primary focus [was] on health care costs… [In this study] not only the health care costs (i.e. costs of care givers, medication and hospitalisation) are included, but also the costs of patients (i.e. out-of-pocket costs, travel expenses), their family (i.e. informal care) and other non health care costs (i.e. productivity losses).

The results were surprising:

… The total … costs over the whole period followed (from 16 weeks of pregnancy until six weeks after delivery) amounted to €3,695 for women who intended to give birth at home and €3,950 for women who intended to give birth in a short stay hospital setting… The costs of pregnancy and delivery are (slightly) higher in the home birth group, while the costs associated with postpartum period are higher in the short-stay hospital birth group.

When looking at the different cost categories, the costs for contacts with healthcare professionals are statistically significantly higher in the home birth group (€138.38 vs. €87.94). There are also statistically significant differences between both groups regarding ‘costs of maternity care assistance at home’ (€1,551.69 vs. €1,240.69, and ‘costs of hospitalisation mother'(€707.77 vs. 959.06).

According to the authors:

… We expected that the costs of home births would be much lower than those of short-stay hospital deliveries. From the results however, it can be concluded that there is no difference in the total costs between the home birth group and the short-stay hospital group. In the home birth group, more costs were spent on maternity care assistance in the postpartum period. This conclusion is in line with the result that the costs of hospitalisation of the mother and child in the postpartum period are higher for the short-stay hospital birth group. In the Dutch obstetric system, women who remain hospitalised after delivery receive fewer days of maternity care assistance at home …. This leads to lower costs for maternity care assistance at home than for the home birth group.

The results of the cost analysis for the actual place of birth showed a large difference in antenatal costs in “week 29-42” between women who gave birth in secondary [physicia] care and women who gave birth in primary [midwife] care. This means that most of the complications during pregnancy arise in the last period of the pregnancy. All respondents were at low risk at the beginning of their pregnancy. When complications occur during pregnancy, their midwife (primary care) has to refer them to much more expensive secondary care…

This study has several major strengths:

1. It involves only women who were considered low risk at the start of pregnancy.

2. The women differ only in their preference for place of delivery. All women would have qualified for a homebirth had they desired one.

3. Since the study considered pregnancy in its entirety, it took into account the additional costs incurred by women who were low risk at the start of pregnancy but became higher risk.

4. The study considered additional costs such as ambulance costs for transport during labor and costs for home care.

5. The study looked at the actual costs of providing services. In the US studies often look at the billing rates which are merely theoretical since hospitals providers are reimbursed for a fraction of the billing rate.

6. The study took place within a system that provides comprehensive care so all costs (including ambulances, home health aides, etc) were readily accessible and could be included.

The authors conclude:

The objective of this study was to give a view of the Dutch obstetric system from an economical perspective. This study provides insight into the societal costs of the two groups of women giving birth for the first time in the Netherlands with different intentions regarding place of giving birth. Because of the high rate of home births in the Netherlands, the obstetric system is currently a topic of debate. In summary, from the results of this cost analysis, it may be concluded that there is no difference in the total costs between low-risk nulliparae who prefer to give birth at home and low-risk nulliparae who prefer to give birth in a short-stay hospital setting.

Several months ago, I discussed a bizarre paper in the midwifery literature. In Homebirth midwives wonder why no one takes them seriously:

Including the nonrational is sensible midwifery, by Jenny A. Parratt, and Kathleen M. Fahy, was recently published in the Australian midwifery journal Women and Birth. This piece has a very simple premise and conclusion: Many principles of midwifery are not supported by science. Rather than modify midwifery to reflect scientific knowledge, it is personally more satisfying to midwives to justify and celebrate their ignorance. Hence, we celebrate!

As an example of the inanity promoted by the authors, I quote this:

For example, when a woman and midwife have agreed to use expectant management of third stage, but bleeding begins unexpectedly, the expert midwife will respond with either or both rational and nonrational ways of thinking. Depending upon all the particularities of the situation the midwife may focus on supporting love between the woman and her baby; she may call the woman back to her body; and/or she may change to active management of third stage. It is sensible practice to respond to in-the-moment clinical situations in this way… Imposing a pre-agreed standard care protocol is irrational because protocols do not allow for optimal clinical decision-making which requires that we consider all relevant variables prior to making a decision. In our view all relevant variables include nonrational matters of soul and spirit.

I referred to the paper in a post earlier today, Midwives have a problem with scientific evidence. It came to the attention of one of the authors who has written in defense. This appears to be a genuine comment from Kathleen Fahy:

I find your rudeness and arrogance breathtaking. You seem to have a very clear view that body and mind (let alone soul) are separate. You are not up to date with the research in neurobiology and psychophysiology which demonstrates clearly the effect of thinking and feeling on human physiology. You might think it is ridiculous that skin to skin contact between a woman and her baby is seen as important in midwifery: it IS important for the woman’s natural oxytocin to be released which does at least two important physiological things; one contract the uterus and two assists with breastfeeding. Is it really your view that without the drug pitocin then women would all be having postpartum haemorrhages? Amy, you sound like a fundamentalist; you need to open you mind to knowledge and critically appraise new research rather than resort to selective reporting and ridicule. Kathleen

The defense is as illogical and unconvincing as the original paper.

1) There is no scientific research in neurobiology or any other field that supports the use of nonrational treatments.

2) There is no evidence that postpartum hemorrhage can be prevented or treated by skin to skin contact between a woman and her baby.

3) Rather than address the scientific evidence on postpartum hemorrhage, Fahy prefers to put words in my mouth. I did not say that all women will have postpartum hemorrhages without pitocin. I said that recommending “supporting love between the woman and her baby” is a flourish of outright stupidity, and Fahy has offered no reason to change that claim.

Caroline Hastie, another Australian midwife and co-author with Fahy and Maralyn Foreur of the new book Birth Territory and Midwifery Guardianship submitted this comment:

In regards to ideas about rationality and the non-rational, you may like to read this book on your journey to start understanding these concepts and why they are so important to supporting birthing women and midwives. Body and soul: a social history of the self

Ms. Hastie’s own book includes such gems as:

During women’s experience of childbirth, midwives also have the capacity to become aware of nonrational power and knowing… Being open to the nonrational can teach midwives about trust, courage and their own intuitive abilities.

And (I’m not making this up):

Nonrational power is inexpressibly unique, diverse and whole at the experiential level…

Spirit is power… Spirit is nonrational, ever moving, and acts in sometime idiosyncratic ways as it is free of what we rationalize as possible and impossible. The direction, force and flow of spirit extend beyond rational boundaries of time, space and matter…

The power of the spirit is the energy underlying all that in the world and the cosmos; it has been given other names, for example Universal Energy and the subtle yet vital energy called qi…

The effort to promote and defend the use of the nonrational in midwifery is astounding. Including the nonrational is not sensible midwifery; it is immature, self-absorbed, dangerous behavior. It reflects the unfortunate obsession among many midwives with their own feelings and need for validation.

Australian midwives are currently protesting the governments plan to bring them under the supervision of physicians. Frankly I regard any attempt to promote the nonrational in midwifery as evidence that midwives cannot be trusted to care for women without direct and continuous supervision by physicians.

The new mantra of midwives and their advocates is “evidence based practice.” Lamaze, the childbirth education organization has changed the name of their blog to “Science and Sensibility” emphasizing the importance of science and promising:

Lamaze education and practices are based on the best, most current medical evidence available, and can help reduce the overuse of unnecessary interventions while improving overall outcomes for mothers and babies.

But midwives and childbirth educators like Lamaze have a problem. The scientific evidence often conflicts with their ideology. They could address this problem in several ways. Midwives could modify their specific ideological beliefs on the basis of scientific evidence. Childbirth educators could question whether ideology has had an inappropriate impact on the promulgation and validation of their recommendations. Both those approaches would involve a threat to cherished beliefs. They, therefore, have taken a different approach. They’ve tried to justify ignoring scientific evidence.

As midwives Jane Munro and Helen Spilby have documented in The Nature and Use of Evidence in Midwifery, midwives were initially enthusiastic about basing clinical practice on scientific evidence. That’s because they had long told each other that midwifery was “science based” while obstetrics was not:

At the beginning of the evidence based practice movement, much of the midwifery profession responded enthusiastically to the potential for change. Critical to this was the publication of resources of a quality not previously available to midwives … Evidence based practice was seen to be offering a powerful tool to question and examine obstetric-led models of care that had dominated the previous decades. The results of such examination could have meant ‘starting stopping’ the unhelpful interventions that had embedded themselves in common practice even suggested that it offered to ‘take us out of the dark ages and into the age of enlightenment’ by demanding that women were only offered care and treatments that had been evaluated.

But (surprise!) it turned out that obstetrics had been based on scientific evidence all along and it was midwifery that ignored the scientific evidence in favor of ideology. As I have pointed out many times, almost all practices exclusive to midwifery (as opposed to copied from obstetrics) have never been tested. They might be valuable; they might be useless; they might even be harmful. No one bothered to check before implementing them because they were based on an approved ideology.

It has been quite a shock to midwives and childbirth educators to learn that most of their own practices have never been scientifically validated. Even worse, from the point of view of ideology, their critique of modern obstetrics flies in the face of the existing scientific evidence. As Munro and Spilby explain:

… [S]ome midwives have not been so enthusiastic [about evidence based practice], viewing the drive to create and implement evidence as a threat to their clinical freedom.

In other words, cherished ideological beliefs conflict with scientific evidence. Thus began the attack on scientific evidence.

As a first approach, midwives and childbirth educators have rejected the definition of evidence. As defined by Sackett, the founder of evidence based practice, it is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” That sounds objective, and evidently, objectivity is a problem. They have attempted to solve that problem by insisting that evidence can only be defined in context. “Context” in this case really means “ideology.”

Scientists see the ideology free nature of scientific evidence as one of its strengths and therefore privilege it as the ideal form of evidence. But Lomas, writing on evidence in midwifery, rejects this privileged status:

[I]t is important that context evidence should not be viewed as any less ‘scientific’. They advocate moving forward from the epistemological argument about what is ‘best evidence’ towards a ‘balanced consensus’ …

The use of the word “consensus” is illuminating. Evidence can only be evidence if it includes the opinions of midwives and childbirth educators, whether those opinions are based on science or not. Indeed, the scientific facts are merely one aspect of evidence. “Social science oriented research” and “the views of stakeholders” are supposed to have equivalent weight.

Such is the genesis of goofy midwifery papers like Wickham’s Evidence Informed Midwifery, and, my personal favorite, Parrat and Fahy’s Including the nonrational is sensible midwifery. When the evidence does not support your claims, the use of adjuncts, including nonrational ones, will justify any beliefs.

The bottom line is this: many midwives and childbirth educators use the term “scientific evidence” merely as a rhetorical device, in the same way that creationism and other form of pseudoscience use the term “scientific evidence.” As Coker details in his article Distinguishing Science and Pseudoscience:

Pseudoscience appeals to the truth-criteria of scientific methodology while simultaneously denying their validity.

Similarly, midwives and childbirth educators invoke the criteria of scientific methodology while simultaneously insisting that their opinions matter more.

It’s official. America hates fat people.

Human beings are constantly searching for socially sanctioned reasons to feel superior to others and in 2009, those who are thin feel mighty superior to those who are not. How else could a college dare to make body mass index (BMI) a graduation requirement?

According to James DeBoy, the chair of Lincoln’s Department of Health, Physical Education, and Recreation, the point of the new policy is to keep students healthy:

“There’s an obesity epidemic,” DeBoy says. “The data are clear that many young people are on this very, very dangerous collision course with heart disease, diabetes, and stroke—health problems that are particularly bothersome for the African-American community.”

The move by Lincoln University in Pennsylvania is ironic to say the least. Proudly billing itself as “The Nation’s First Black University,” Lincoln seems to have forgotten why it exists in the first place. For two hundred years, irrelevant criteria, like race, have been deemed important requirements for entrance to and graduation from college. Not only has Lincoln University introduced an irrelevant requirement for graduation, but the administration has managed to choose an irrelevant requirement that is more likely to affect black students than those of other races.

Henceforth, all students will be required to endure a physical examination to determine BMI. If the BMI exceeds the arbitrary limit of 30, the student must enroll in “gym” class to qualify for graduation. Lincoln University justifies it discrimination against the overweight by invoking the purest of motives; they’re moved by the humanitarian impulse to preserve health and prevent illness. Oh, really? So why is it bad to overeat but okay to sleep around?

Arguably, promiscuous sexual behavior is responsible for more illness, emergencies, and anguish during the college years than promiscuous consumption of food. Promiscuous sexual behavior is associated with dramatic increases in sexually transmitted diseases, leading to serious infections, hospitalizations, and long term health problems like infertility and potentially fatal diseases like AIDS. Unintended pregnancy causes health problems and psychological distress. If Lincoln University is really concerned about student health, wouldn’t it make more sense to include a pelvic or penile examination as a graduation requirement? Those with sexually transmitted diseases could be forced to attend “health” class to learn about responsible sexual behavior.

And as long as we are talking about regulating student behavior, why is it bad to overeat but okay to drink yourself to death? Alcohol abuse is arguably the most serious health problem at colleges. Perhaps Lincoln University should consider locating sobriety check points throughout the college campus. Random breathalyzer testing could identify students who drink to excess, and then they can be required to take a class on responsible drinking before qualifying for graduation.

Indeed, there are colleges that have instituted specific lifestyle guidelines on drinking and premarital sexual activity, but they do so for religious reasons. They explicitly favor certain lifestyle choices over others and are not afraid to say so. They do not camouflage their views with pious claims of preserving the health of their students.

Regardless of what the administration of Lincoln University tells the world, or even each other, about their motivations for instituting a BMI requirement, the de facto discrimination against overweight students has very little if anything to do with health. If the university were truly worried about student health, they would be addressing the most important threats to student health first, instead of ignoring those altogether. Lincoln University has decided to discriminate against the overweight for the oldest reason in the book: because they can.

Prejudice against the overweight is one of the last remaining social sanctioned prejudices. Never mind that Lincoln University is in the business of education and should be granting degrees based on educational criteria. The opportunity to single out, embarrass and penalize those who overeat was just too hard to resist. Perhaps the administration might consider taking an easier and less expensive route and simply force overweight students wear apparel emblazoned with a scarlet “O.”

When we are raised to believe that prejudice against those who look different is wrong, it is a relief to find a prejudice against those who look different that is right. Overt racism, sexism, ageism and even homophobia are out. Fortunately, discrimination against the overweight has never been more in.

Every year, for lack of timely screening and treatment, hundreds of women will die of breast cancer. No, I’m not talking about the change in mammography screening guidelines for women aged 40-49. I’m talking about women of any age who will not have access to mammography or treatment if a healthcare reform bill is not passed. Without health insurance, these women will die preventable deaths.

Republicans have exploited the release of the new mammography guidelines to argue that the Obama administration does not care if more women die of breast cancer. Ironically, their opposition to a public option for health insurance virtually condemns up to 600 women per year to die a preventable death from breast cancer. Republicans apparently believe that insured breasts matter more.

That seems a rather bizarre distinction to make. I could understand, though not agree, if they claimed that Republican breasts matter more. They have an interest in making sure that women who will vote for them will live to return to the polls each year. But the distinction between women who are insured and those who are uninsured crosses political lines.

I could understand, though not agree, if Republicans insisted that profits matter more and supported the new guidelines to benefit their friends in Big Insurance who depend upon them to vote against healthcare reform. The US Preventive Services Task Force recommended ending routine yearly mammograms for women aged 40-49 because the data show that the risks of false positives, unnecessary biopsies and unnecessary breast cancer treatment outweigh the benefits. That can only be helpful to insurance companies who can increase profits by reducing marginally effective and ineffective procedures.

But, instead, the Republicans claim to base their opposition to the new screening guidelines on their reverence for life. They insist that President Obama, in a crass effort to save money, is rationing mammography. To hear them tell it, it is worth virtually any amount of money to save even one additional woman from becoming a breast cancer fatality. Yet the reality is that they are only concerned about the breasts already covered by health insurance.

Republicans are apparently unmoved by the fact that up to 600 women die each year because their lack of health insurance prevents timely access to mammograms, diagnostic procedures and breast cancer treatment. Insuring the breasts of the uninsured would have a far larger effect than merely saving those 600 lives (each one of which is supposedly valuable enough to justify the spending of any amount of money). That’s because the benefit would not be limited to preventing deaths from breast cancer. Current estimates suggest that as many as 45,000 people die preventable deaths every year because of lack of health insurance.

Republicans claim to oppose healthcare reform because it is too expensive. But according to them it’s worth almost any amount of money to prevent a single death. They also oppose healthcare reform because they claim it will lead to rationing. But there is no more brutal form of rationing than to ration health insurance itself, giving it arbitrarily to those who happen to work for an employer who chooses to provide access to insurance and denying it to everyone else.

Do insured breasts really matter more? Or are the Republicans hypocritically exploiting women’s fear and misunderstanding over the new guidelines in order to score political points? If Republicans truly care about making sure that not a single woman dies a preventable death from breast cancer, they’d be clamoring for a quick vote on healthcare reform, and they’d vote for a public option as the best way to end preventable deaths from breast cancer.

Otherwise, we’d be forced to conclude that Republicans don’t really care at all about saving lives and are just a bunch of hypocrites using fear mongering to divert attention from their self serving support of the insurance industry. And they wouldn’t want us to reach that conclusion, would they?

There has been much righteous indignation expressed in response to the new US Preventive Services Task Force changes that no longer recommend routine mammograms for women aged 40-49. The indignation takes two basic forms. The first is the assertion that it is worth any amount of money to save even one life. The second is that the recommendations are cynically motivated by a desire to save money by “rationing” healthcare.

Yet people fail to consider that we make policy decisions all the time because we don’t believe that it is worth any amount of money to save even one life, and because we want to save time and money. Consider the case of highway speed limits.

It is well known that lower speed limits decrease fatalities. Since over 37,000 people die each year on our nation’s highways, this is not merely an academic point. If we reduced the highway speed limit to 25 mph we could undoubtedly save tens of thousands of lives. If, in addition, we mandated that all cars were armored like Sherman tank, we might be able to save every one of those more than 37,000 people each year. Yet we don’t do that. Why? Because it would cost time and money and we don’t think that it’s worth it.

We won’t even take less drastic measures to reduce highway fatalities. Knowing full well that increasing the highway speed limit from 55 mph to 65 mph would cost lives even as it saved time. That’s exactly what happened. According to researchers Ashenfelter and Greenstone:

In 1987 the federal government permitted states to raise the speed limit on their rural interstate roads, but not on their urban interstate roads, from 55 mph to 65 mph for the first time in over a decade. Since the states that adopted the higher speed limit must have valued the travel hours they saved more than the fatalities incurred … We find that the 65 mph limit increased speeds by approximately 3.5% (i.e., 2 mph), and increased fatality rates by roughly 35%. In the 21 states that raised the speed limit and for whom we have complete data, the estimates suggest that about 125,000 hours were saved per lost life. Valuing the time saved at the average hourly wage implies that adopting states were willing to accept risks that resulted in a savings of $1.54 million (1997$) per fatality …

Of course not every hour saved is money earned, so the real cost per fatality is probably far lower. Regardless, as a matter of policy, the American people don’t think it is worth the amount of time and money it takes to save one additional person from a fatal car crash.

The relationship between fatalities and the highway speed limit is just one example of the myriad policy decisions that are made every year that must balance lives saved against cost. Although opponents of the new mammography guidelines are trying to characterize such decisions as tawdry at best and immoral at worst, there is no other choice. We are always forced to draw arbitrary guidelines. Why, for example, should the highway speed limit be 65 mph? Why not 75 mph? Or for that matter, why not 69.3 mph since there is nothing particularly special about whole numbers ending in 5? Each decision represents an arbitrary balancing of costs against human lives.

Similarly, though people claim to be outraged at dropping the recommendation for yearly mammograms in women aged 40-49, why aren’t they clamoring that the recommendations should be extended to yearly mammograms for women aged 30-39? If they truly believed, as they claim that they do, that it is worth any amount of money to save one life, they should be insisting on screening for women aged 30-39 since breast cancer can occur in that group, too.

Moreover, there’s nothing special about whole numbers that end in 0. Why not recommend yearly screening women aged 28-39? For that matter, there’s nothing special about yearly intervals. Why aren’t they recommending screening for all women every 6 months instead of every 12 months? Surely we could save a few more lives that way, too.

The fact is that we are forced to make relatively arbitrary policy decisions when it comes to safety issues of any kind. We are always forced to balance benefits and costs. We don’t really believe that it is worth any amount of money to save even one life. We don’t even believe that it is worth getting to our destination a little later to save 37,000 lives lost on the highway each year.

That’s why the outrage over rationing is entirely misplaced. If by rationing people mean considering cost when making safety decisions, we ration every day in many ways. We live in the real world, and in the real world there is not unlimited money. A dollar spent on mammograms is a dollar not spent on another form of healthcare that may have a much better benefit to cost ratio. It is not rationing to suggest that some money spent on mammograms might be better spent elsewhere. It is merely common sense.

Americans, particularly American women, are shocked, bewildered and angered over the change in mammography guidelines. Many emphasize that it is changes like these that foster distrust in the medical system and lead people to seek alternative practitioners. That’s unfortunate because the change in guidelines highlights one of the most important strengths of modern medicine: medicine is constantly changing in response to new scientific evidence; “alternative” health doesn’t change because its not based on scientific evidence; its based on belief.

In other words, what lay people perceive to be the biggest weakness of modern medicine is actually its biggest strength.

Medicine is like a frost covered windshield. We cannot yet see the full view because we lack a complete understanding of how the body works, and we lack a complete understanding of many diseases, particularly cancer. Unlike the real world, where we can totally wipe away the frost obscuring our view through the windshield, in medicine we have to content ourselves with ever increasing clearing of various spots. And unlike the real world, where we can wait to totally wipe away the frost before we start to drive, in medicine we must keep moving forward despite our incomplete view.

We get into trouble when we try to shortcut the process by making assumptions instead of waiting for definitive evidence. Medical screening is just one area in which we’ve been forced to backtrack on our assumptions when new evidence becomes available. We have assumed that because some screening is good, more screening is better. That assumption was never supported by scientific evidence.

There is a large body of scientific evidence showing that biennial mammographic screening of low risk women aged 50-75 leads to lower death rates from breast cancer. There is no evidence that the same approach has a similar impact on death rates in women aged 40-49. Yet we implemented routine screening because we assumed that more screening is always better. The thinking was “better safe than sorry.”

With more experience and with more scientific evidence we’ve cleared away more of the mist obscuring our view. Routine yearly mammographic screening in low risk women has minimal if any impact on death rates. That’s because it picks up small tumors that aren’t likely to develop into aggressive cancer and does not increase the diagnosis rate of the aggressive tumors that are likely to kill women.

Paradoxically, the failure of routine screening mammography has convinced American women of its success. All of us know women, or are women, whose small breast cancer was diagnosed by a routine mammogram, who had lumpectomy, and perhaps radiation or chemo, and are now cured. The scientific evidence tells us that almost all of those cancers would have remained stable or possibly even disappeared if they had not been found and treated.

In some ways, that’s even more distressing information than the change in mammography guidelines. It means that thousands of women have undergone unnecessary biopsies, unnecessary surgeries and unnecessary chemo and radiation, not to mention unnecessary anxiety and fear. We didn’t cure these women. We treated them even though they didn’t need it and then took credit for what would have happened anyway.

A disaster like this would never happen in “alternative” health because it doesn’t change with new scientific evidence since it is not based on scientific evidence. That’s one of the reasons why “alternative” health remedies are never tested before they are implemented. What would be the point? And it’s one of the reasons why advocates of “alternative” health ignore evidence that their treatments don’t work.

“Alternative” health does not advance new theories, acquire new information and modify theories based on new information. The same “remedies” that were used hundreds of years ago are offered now as if nothing has changed in the interim. Classic books in “alternative” health tend to have only one edition. There’s no need to have more editions when nothing changes.

In “alternative” health, things are simple, remedies are static, and certainty is prized. That is very comforting to human beings who value certainty in an uncertain world. Medicine is messier. The human body is complicated, and disease is complicated. We are constantly acquiring new information about both. Treatments and medical recommendations change in response to this new information. No one can be sure that the therapy recommended today won’t be superseded by a better therapy found tomorrow.

Only one thing is certain. The recommendations issued this week are sure to be amended at some point in the future, most probably because we find a better screening tool for breast cancer than mammography. We need, and we are looking for, a screening tool that will be able to tell the difference between aggressive breast cancers and those that will go away on their own.

It is unfortunate that we are periodically forced to reassess medical recommendations. However, it would be tragic if people viewed this reassessment as a failure and stopped listening to recommendations. Returning to the windshield analogy: it is a shame that we sometimes need to change course when our view expands, but it would be tragic if people decided on that basis to drive without ever looking through the windshield at all.

What would you think if the package insert for your new medication said the following?

Our company, Drugs4All has tested this medication in 20,000 people and collected copious data about its effects. But we made a promise to Drugs4All shareholders that we will not let anyone see that data unless they can demonstrate that they will use it to promote the well being of our company.

Therefore, we’ve created a two-step process for access to the data. If you’d like to learn about the safety of this medication please complete the application attached and explain your commitment to the well being of Drugs4All. Please include the your name and the names of anyone you have ever associated with. A committee will review your ideological commitment to the well being of Drugs4All to be sure that you will not use the data to harm our interests.

If you meet with our approval you will be eligible to see our safety data. That’s step 1. In step 2 you must sign our non-disclosure agreement promising not to share the data with anyone else under the pain of legal penalties.

We’re sorry for any inconvenience, but our first commitment is naturally to our shareholders, not to our customers.

Your first assumption might be that Drugs4All withheld the safety data from the public because it shows that the drug is not safe. Therefore, they must restrict access to the data to those who can demonstrate in advance that they are committed to the interests of Drugs4All and have instituted penalties to be sure that no one else sees it.

Crazy, right?

Evidently not. This the procedure that the Midwives Alliance of North America (MANA), the official organization of homebirth midwives, has instituted to protect the safety data they have gathered in the past decade. In periodic public announcements over the past few years, MANA has announced the existence of the data and promised that it will be the largest and most extensive database of its kind.

Unfortunately for MANA, though, it does not show what they want it to show. Since their first commitment is to homebirth midwives, not their patients, they have publicly announced that only those who pass an ideological litmus test and sign a legal non-disclosure agreement will be allow access to the data.

According to the MANA Handbook for Researchers Interested in Obtaining Access to the Manastats Database:

[MANA} is responsible for representing the midwifery community in its relationship with investigators…Therefore [MANA] expects all investigators interested in collaboration with this community to consider how they can cooperate … and to describe how they intend to do so in their request for data access.

Upon approval of a research application, access will be predicated on the signing of a … a Confidentiality and Non-Disclosure Agreement…

It is difficult to imagine a more unethical procedure for gaining access to the database. MANA has made several things clear.

1. It’s first priority is the benefit of its shareholders.
2. MANA does not believe that patients have any right to know the truth about homebirth safety
3. The data is potentially so damaging to homebirth midwives that it must not be allowed to get out to anyone who hasn’t been vetted in advance and promised to keep it secret from the public.

It does not take a rocket scientist to surmise that MANA’s own data show that homebirth with an American homebirth midwife is not safe. Withholding that information from patients is both unethical and immoral.

MANA should publicly release all their available safety data immediately. Will that hurt the employment prospects of homebirth midwives? Probably, but that’s just too bad.

No one can make an informed decision about homebirth without access to information. But I guess that’s the point. An informed patient might not become a customer, and as MANA has helpfully informed us, representing the interests of homebirth midwives is its most important priority.

Everyone has heard about women faking orgasm, but most people assume that men would never do so, and that it is impossible in any case.

A new study in the Journal of Sex Research aims to over turn the conventional wisdom. Men’s and Women’s Reports of Pretending Orgasm, Muehlenhard and Shippee, Journal of Sex Research, 46, 1–16, 2009 investigated the issue among college students:

Research shows that many women pretend or “fake” orgasm, but little is known about whether men pretend orgasm… Participants were 180 male and 101 female college students … Participants completed a qualitative questionnaire anonymously. Both men (25%) and women (50%) reported pretending orgasm (28% and 67%, respectively, for PVI-experienced participants). Most pretended during PVI [penile vaginal intercourse], but some pretended during oral sex, manual stimulation, and phone sex…

The authors found that 50% of women reported having faked orgasm, and, surprisingly, 25% of men also reported faking orgasm. However, the rationale and reasons varied dramatically between the two groups. Women were more likely to fake orgasm because they considered themselves incapable of achieving orgasm in similar situations, or at all. The main reason offered by women for faking orgasm was to protect a partner’s feelings. In contrast, the men who faked orgasm most often did so because they were either too drunk to perform or had had one more orgasms within the previous hours. The most common reason for faking orgasm offered by men was wanting to end the encounter.

The authors helpfully provide examples:

My 1st girlfriend in high school and I lost our virginity to each other. She wanted to have sex ALL the time, even at times I wasn’t—Approx. 5–7x daily—able to. I would motivate myself, we’d have sex, and she wouldn’t stop till we both orgasmed. I’d fake it to get it over with. (After the 3rd orgasm, it’s REALLY hard to go again.)

As the authors explain:

Men most often wanted sex to end because they were tired or wanted to sleep. For example, one man wrote, “After a while my body was getting tired and worn out so I decided to act like I came so she would get off of me.”

Men were more creative than women in pretending. While 90% of women reported acting out orgasm, only 78% of men faked orgasm in that way.

Over one-fourth of the men … reported telling their partners after the supposed orgasm (e.g., “I was getting tired and she wasn’t that cute so my dick couldn’t stay hard so I just told [her] I came and I got up and left,”)… Interestingly, several men (18%), but no women, mentioned that they had pretended by stopping having sex. One man, who checked that he had pretended, mentioned no method of pretending other than stopping … One wrote that he pretended by “[saying] That felt good and stopping.” Another wrote, “I just stopped and told her I was done and left.”

The authors were apparently exhaustive in their analysis, but, curiously, one important detail was not examined. The questionnaires asked if the person had ever faked an orgasm, not how often they had done so. So we do not know if men the men who faked orgasm did so habitually or only when drunk or otherwise impaired.

Though men and women differed in many parameters, on one they were united. Most women and most men who faked orgasm did so to please the men. Women faked orgasm to make the men happy, and men faked orgasm to make themselves happy.