You really have to hand it to homebirth midwives. Who else could resurrect third world causes of childbirth death in the first world?

Like their ideological soulmates, the vaccine rejectionists, they imagine re-enacting the “olden days.” And just like the vaccine rejectionists, who are single handedly bringing back, measles, whooping cough, and other vaccine preventable diseases that routinely killed children in the “olden days,” homebirth midwives are bringing back intrapartum stillbirth.

Intrapartum stillbirth is the death of a baby during labor. It is extraordinarily rare in the US today. A woman who shows up at a hospital in labor with a live term baby is almost certain to give birth to a live baby. Not so in the third world. Asphyxia (lack of oxygen) during labor is a leading cause of death in countries where women lack access to hospitals and obstetricians. Why? Because birth attendants in the third world have no way to tell if a baby is not receiving enough oxygen in labor and no way to fix it by C-section or forceps even if they could tell.

Similarly, homebirth midwives also can’t seem to tell if a baby is not receiving enough oxygen in labor, and when and if they do figure it out, they lack access to the obstetricians, anesthesiologists and operating rooms that could easily save the baby’s life.

Consider these two cases of homebirth death recently in the news:

1. ‘Perfectly healthy’ baby boy suffocated in womb:

The baby’s parents, Sarah Williams and Emmet Heneghan, had given evidence the previous day. Mr Heneghan described the scenes from that night in their home in Louisburgh, Co Mayo, in May 2011 as “farcical” as the baby’s heartbeat began to fade.

He had suggested that they go to the hospital, but the midwife’s car would not start so they had to travel in his.

Ms Williams also gave evidence that a doctor had told her that if they had left for the hospital earlier, her son would be alive.

Self-employed midwife Christina Engel, of Ballinrobe, Co Mayo, said she called the hospital to declare an emergency transfer as soon as she noticed the foetal heartbeat decelerating.

2. South Carolina has suspended the license of a free standing birth center and two of its midwives because of an intrapartum stillbirth.

The woman, who arrived about 9:43 p.m. Aug. 29, was 8 centimeters dilated by the next morning, according to a 7:15 a.m. exam, the documents said.

Then between 6:05 and 6:53 p.m. Aug. 30 [11 HOURS later!], the baby’s heart rate dropped from the 130s to the 110s while in utero. Just before 7 p.m., the documents note that “oxygen was applied at 10 liters per minute via a face mask.” But no physician was consulted, the documents said.

Around 7:30 p.m., the midwives took the woman to the hospital in her own vehicle, without consulting a physician or calling for an ambulance, documents said.

The midwives contacted Piedmont Medical Center and told them they were “en route with a mother that has fetal intolerance to pushing, meet us downstairs,” documents said.

When they arrived, a cesarean section was performed, and the baby was born without a heartbeat. Hospital personnel tried to revive the baby but were unsuccessful, state documents said.

Another third world cause of death is lack of access to someone with knowledge and equipment for advanced resuscitation:

3. The story of a blogger who is “pursuing healthy living.”

Finally, after 1 ½ – 2 hours of pushing, her head was coming out. I wasn’t sure she was really coming until they told me to reach down and grab her. She was still pink at this point. I reached down and grabbed her (under her arms I think) and started to help pull her out. They told me later that the moment that I grabbed her was when her coloring and muscle tone suddenly changed. They had never seen a baby’s color change so quickly before. She went from pink to white/blue, and she fell limp. I remember her head falling to her shoulder as I was grabbing her. From the sudden change in color and muscle tone, Sara knew something was wrong. As I pulled out most of her body, Sara took her from me and immediately started trying to get her to breathe.

What is it with these homebirth midwives and their refusal to call an ambulance?

During the pregnancy, Sara had explained that in case of transfer, she just drives to the hospital and calls ahead so they know she is coming and what is going on. If she called an ambulance instead, we’d have to wait for them to get to us, THEN drive to the hospital, so just driving herself gets the emergency to the hospital faster. (Not to mention that ambulances cost $$$$$.) It was also night time and we only live a mile from the hospital in a small town, so there should be virtually no traffic and she could drive quickly.

And, as usual, the mother refuses to take responsibility for her choices. In this case, apparently, its God’s fault:

It is hard to describe, but I genuinely felt peace at that point, that it didn’t really matter whether my baby lived or died or had complications, because I knew that whatever the outcome was, would be the way God wanted it to be. He wouldn’t make or allow this situation to happen if it weren’t for a reason. If God wanted her well, He would provide the miracles for her to live. If she died, then that was what was intended for her. God wouldn’t let something happen that was not the plan. Things were happening the way they were for a purpose. So I didn’t need to worry.

And once again, the drive to the hospital, in the midwife’s car turns into a farce:

On their way to the hospital, they hit a dip in the road too fast, which triggered some sensor in the car, shutting off all the electronics, and thus shutting down the car. Somehow, the BlueTooth was still working though, and they called 911. Sara had my baby in the towel and they started running (without shoes on, I might add) to the hospital. The 911 dispatcher had tried telling her to wait in the car, but she told them the policemen could catch up with her, as she was NOT waiting… After running maybe 1/3 of a block, a policeman picked them up and drove them the last 3 blocks to the hospital…

The end result:

When my baby arrived at the hospital, the doctors and nurses administered CPR and tried 3 times to intubate her. They gave her 3 doses of adrenaline/epinephrine, but couldn’t get a good heartbeat. At one point, they could get a heart rate of 60 (and it fleetingly even went up to 80), but it wasn’t a full open-close valve action…It was really just a flutter, forcing the heart to move without really beating. The heartbeat that they did get was short-lived and she never took a breath…

Dr. Pedi then tried breaking the news to DH that there wasn’t anything else they could do and that she was gone…

These are anecdotes to illustrate the point, but hard data shows the extraordinary epidemic of third world deaths at first world homebirth.

In March of this year, Judith Rooks, CNM released the most comprehensive homebirth statistics ever collected in the US.

The overall all rate of perinatal death at planned homebirth with a LICENSED midwife was 800% higher than comparable risk hospital deaths. While the rate of intrapartum death of term babies in hospitals is so small that it is effectively zero, in just one year alone three (out of 1235) babies dropped into a homebirth midwife’s hands unexpectedly dead … just as often happens in the third world.

Homebirth increases the risk of neonatal death because homebirth has resurrected third world causes of death in the first world.

Way to go, homebirth midwives!

Good, old Hannah Dahlen. I can always count on her to say something idiotic that gives us insight into hijacking of midwifery by biologic essentialists. Those are the women who think a woman’s vagina, uteri and breasts are more important than her intelligence or her comfort.

You remember Dahlen? She’s the spokesperson for the Australian College of Midwives who has given us such gems as:

A common concern with water birth is that the baby could try to breathe underwater and drown. But healthy babies have what’s called a diving reflex (or bradycardic response), which causes the infant to hold his breath when under water. The reflex is stimulated via the the infant’s facial skin receptors, which detect the water and inhibits breathing.

Sorry, Hannah, the diving reflex works only in COLD water. Anyone with a modicum of obstetric knowledge knows that babies are happy to aspirate warm fluid. That’s why they do in utero to expand their lungs and practice breathing before birth.

And, my personal favorite:

While the birth of a live baby is of course a priority, perinatal mortality is in fact a very limited view of safety.

Really? On what planet would that be?

Apparently that’s the way it is on Planet Midwifery where Dahlen and her colleagues reside, a through the looking glass world, where the acme of childbirth is not a healthy mother and healthy baby, but, rather, an unmedicated vaginal birth.

What’s Hannah come up with today?

Dahlen is incensed that any woman might value avoiding a lifetime of urinary and fecal incontinence over the ultimate achievement of unmedicated vaginal birth.

Dahlen, in a comment to the Australian newspaper WAToday, is responding to speech by Dr. Peter Dietz who is a urogynecologist. That means that he spends his professional life in large part repairing the damage from vaginal births. Dr. Dietz told a recent meeting the Royal Australian and New Zealand College of Obstetricians and Gynaecologists that women are suffering substantial pelvic floor damage in the quest for natural birth, because vaginal birth carries a risk of 30 per cent to 50 per cent of substantial pelvic floor damage.

Major pelvic floor damage can result in years, if not a lifetime, of misery. It can mean being unable to hold urine and feces, being unable to leave the house because of embarrassment and being unable to have sex.

But apparently on Planet Midwifery, that’s far less important than having a baby transit your vagina.

According to Dahlen:

There is no doubt pelvic floor injuries are a threat to the health of child-bearing women. It is imperative we continue research in this area and work to make birth safer. But women need comprehensive information that goes beyond the pelvic floor when considering the pros and cons of vaginal birth versus caesarean section.

Umm, Hannah, you apparently do not realize that we have “done research” in this area and the research shows that vaginal birth is the single biggest risk factor for pelvic floor damage.

But who cares about something as trivial as incontinence, right?

Dr. Dietz also criticized the effort to reduce epidurals, calling it, correctly, “reprehensible and anti-Hippocratic.”

Dahlen responds with this bit of nitwittery:

There is no intent to deny a woman an epidural if she wants one; we need to ensure they are not used unnecessarily.

Wait, what? They’re giving epidurals to people who aren’t in pain?

That can’t be what Dahlen means. After all, epidurals are widely used in other areas of medicine like general surgery, orthopedic surgery and management of chronic pain. Dahlen doesn’t mean those people. I’m sure she thinks it’s just fine to use epidurals ease surgical pain or cancer pain. No, Dahlen thinks it is “unnecessary” to treat childbirth pain.

Why? Because it might lead to something other than the pristine unmedicated vaginal birth so valued on Planet Midwifery.

And then there’s this, infinitely more revealing about contemporary midwifery than it is about anything else:

Dr Dietz’s statement that ”human childbirth is a fundamental biomechanical mismatch, the opening is way too small and the passenger is way too big,” provides a real insight into why the caesarean section rate may be so high in this country.

If health professionals truly believe this, then what chance do women have to feel confident in their bodies and their capacity to give birth?

Because on Planet Midwifery, the most powerful force isn’t gravity, it’s magical thinking.

Earth to Planet Midwifery: do you hear me?

Listen carefully:

There is NO SUCH THING as an unnecessary epidural. Childbirth epidurals are always and only given to women who have so much pain that they want one.

A midwife has NO BUSINESS deciding whether a woman “deserves” to get an epidural. We have a word for that behavior; it’s paternalism, and it’s reprehensible and un-Hippocratic.

Confidence has no more impact on a woman’s ability to have a vaginal birth than it has on her ability to have a child of a desired gender.

Women need to understand that midwives like Hannah Dahlen do not have their interests at heart. How could they when they don’t care if babies die, when they don’t care if women become incontinent and when they don’t care if women are in agonizing pain? Midwives like Dahlen care about one thing only: themselves and their associated ability to maintain control over patients.

Midwives aren’t as capable of obstetricians at saving babies lives; hence “perinatal mortality is in fact a very limited view of safety.”

Midwives can’t prevent pelvic floor damage by performing C-sections; hence incontinence pales in importance to vaginal delivery.

Midwives can’t perform C-sections to save the lives of babies in distress or deliver babies who are too large to pass through the pelvis; hence they pretend that it is doctors’ and patients’ “lack of confidence” in women’s bodies that keep midwives from ensuring a vaginal birth for every patient.

The questions for women are these:

Do you want to give birth on Planet Midwifery, where your vagina is more important than your brain, where your pain is ignored and where you are blamed if you do not achieve the ideal unmedicated vaginal birth? Or do you want to live in the real world where people care about whether your baby lives or dies, whether you are rendered incontinent, and want to ease your agony, not celebrate it? It’s up to you to decide.

Laura Helmuth has a fascinating series on longevity of at Slate Magazine. Yesterday’s installment was about maternal mortality. The title, The Never-Ending Battle Between Doctors and Midwives. Which Are More Dangerous?, is somewhat awkward, but the piece itself is fascinating.

She recounts the history of obstetrics, including the early 20th Century when doctors’ desperate desire to do something about maternal and perinatal mortality outstripped their understanding of their own tools.

Things got worse as obstetricians started professionalizing and coming up with new ways to treat—and often inadvertently kill—their patients. Forceps, episiotomies, anesthesia, and deep sedation were overused. Cesarean sections became more common and did occasionally save women who would have died of obstructed labor, but often the mother died of blood loss or infection… Women giving birth in hospitals were at greater risk than those delivering at home. Disease and infections spread more readily in hospitals, and doctors were all too eager to use surgical equipment.

She includes a graph of maternal mortality similar to those I have posted in the past.

Doctors began to use their technology more judiciously and new discoveries led to a massive and sustained drop in maternal mortality (and a comparable drop in perinatal mortality).

Doctors cleaned up their acts, too. A series of reports in the 1940s linked high death rates to improper medical procedures. Training improved, and doctors abandoned the most dangerous techniques. Complications from C-sections declined steadily. Medical researchers now rigorously evaluate success rates and risks of new techniques and drugs…

Improved maternal survival eventually did turn into one of the great public health and medical achievements of the 20th century—it just took an unconscionably long time. The good news today is that, globally, maternal mortality is continuing to decrease. More women are surviving childbirth, and that’s a big reason—and one of the most joyful reasons—why lifespan is continuing to climb in the 21st century.

Not surprisingly, as technology drove down rates of maternal and perinatal mortality, women flocked to hospitals to give birth. Midwifery has never really recovered.

But midwives have fought back, mainly by pretending that the massive decreases in maternal and perinatal mortality didn’t actually occur, and that childbirth was always as safe as it is today.

Helmuth notes:

The midwives and doctors, though—they’re still tangling. Midwives accuse doctors of endangering women by continuing to perform too many unnecessary procedures. Doctors accuse midwives of allowing pregnant women and newborns to die of preventable deaths.

She uses homebirth as a case in point:

The main battlefield today is over home births. About 1 percent of women in the United States choose to give birth at home. Counterintuitive as it may sound at first, they often cite safety concerns—they’re worried about unnecessary procedures if they give birth in a hospital.

Helmuth has an awesome takedown of homebirth midwives in general and Melissa Cheyney in particular:

Melissa Cheyney is an anthropologist at Oregon State University as well as a home-birth advocate and midwife. She reports that women who choose home birth “value alternative and more embodied or intuitive ways of knowing.” Home-birth advocates say women are better off giving birth in a comfortable environment, letting nature take its course.

I’m personally opposed to letting nature take its course—nature will kill you. And “intuitive ways of knowing” is just a flowery term for “ignorance.”

Helmuth appears to unaware of the confirmatory data from Oregon that shows that planned homebirth with a licensed midwife has a perinatal mortality rate 9 times higher than comparable risk hospital birth.

In the end, it’s obstetricians for the win!

But when you take a world-historical look at childbirth, it’s not midwives and cozy home births that get credit for making maternal death such an unthinkable outcome today. One of the great victories of modern times is that childbirth doesn’t need to be natural, and neither does the maternal death rate. It’s modern medicine for the win. Doctors may have killed a lot of women in the first part of the 20th century, but they can save your life today.

I’m pleased to report that the judge agreed with our arguments and those of the Electronic Frontier Foundation/Digital Media Law Project of Harvard Law School and denied Gina Crosley-Corcoran’s motion to dismiss my lawsuit. The case will be going forward in Massachusetts.

EFF makes the valid point that even a two-week improper removal of lawful speech from the public domain “‘causes significant injury . . . where time-sensitive or controversial subjects are involved and the counternotification remedy does not sufficiently address these harms.’

And:

Because, for present purposes, “a knowing and material misrepresentation” is adequately pled, defendant’s motion to dismiss is DENIED.

You can read the full opinion here:

https://dl.dropboxusercontent.com/u/27713670/Tuteur-20130910_Court_order_denying_motion_to_dismiss.pdf

Another day, another baby who didn’t have to die at homebirth.

According to The Irish Times:

A couple who prepared for what they hoped would be an idyllic home birth by lighting candles and playing soothing sounds on their stereo ended up devastated when their baby was stillborn, an inquest heard today.

Too bad they thought candles and music constituted a perfect birth. Personally, I think a live, healthy baby makes a perfect birth and candles and music be damned.

What happened? The story follows the usual homebirth disaster script:

1. A long labor:

On May 23th, 2011, she awoke with abdominal cramps. Ms Engel arrived at about 11.30am. She again arrived at about 6pm and at about 10.30pm told her she could see “the top of the child’s head, his black hair”.

At around 12pm she said to the midwife that she felt it was taking too long, and just after 1am she said it again that she couldn’t get the baby out.

2. Lack of appropriate fetal monitoring and resulting in the “sudden” loss of the baby’s heartbeat:

The midwife told her to push harder but at about 1.30am the baby’s heartbeat had changed and she could not get a reading.

3. The father who insists that they should take the mother to the hospital.

… [H]er partner, suggested it was time she go to the hospital and the midwife agreed…

He said that at approximately 12.30am or 1am he turned off the music. The mood intensified. He saw and heard the baby’s heartbeat diminish and he had enough of what he was seeing and said straight out: “let’s go to the hospital”.

4.The failure to call an ambulance.

5. Delay in getting to the hospital:

However, the midwife’s car would not start and they had to transfer oxygen into her partner’s car. The three of them drove to the hospital in Mr Henaghan’s car.

By the time they got to the delivery suite it was 3am. Staff did an ultrasound on the baby and could not get a reading. The baby was stillborn at 3.23am.

6. The frantic attempts of hospital staff to resuscitate the baby, attempts that ultimately failed.

7. The midwife’s regrets:

[The mother] said that in the hospital immediately after it was clear that Kai had died, Ms Engel [the midwife] said she would never do a home birth again as long as she lived and kept saying “I am so sorry, I am so sorry.”

8. Failure to appropriately monitor the baby’s heart rate:

There was an “unfortunate absence” of foetal heart monitoring records in the medical notes.

9. The midwife changing her story and denying culpability:

In evidence today Ms Engel denied stating in the hospital after the stillbirth she would never do another home birth and also denied being reluctant to transfer her patient to hospital.

She also said she had carried out regular heartbeat checks during the attempted delivery and denied her car was unreliable, stating the problem starting it had been “transient”.

10. The classic exchange of the “birth experience” for the life of the baby:

[The father] said his girlfriend wanted to go down the route of having as natural a birth and pregnancy as possible and contacted Ms Engel, the only local midwife in Mayo. She only wanted to go to hospital if it meant the baby’s birth was at risk.

[He] said: “As part of Sarah’s natural birthing plans she had organised some music or sounds on the stereo to be played, some candles to be lit.

“Every aspect of the house was set out in the way she wanted it for the day of the birth.”

Too bad she didn’t worry more about the health of the baby, and less about an idyllic homebirth.

When it comes to having zero insight, it’s really hard to beat homebirth midwives. They are so totally clueless about how their own behavior comes across that homebirth midwives like Wendy Gordon, CPM, MANA (Midwives Alliance of North America) executive, can actually write an inadvertently hilarious blog post like this: Why ALL Midwives Should Care About What’s Going On With Midwifery International.

I wrote recently about the charge leveled at Midwifery International, an organization that promotes medical tourism of homebirth midwives. To her credit, Gordon acknowledges that she exploited women of color in the developing world in order to get “catches.” But, of course, she excuses herself because “she didn’t know” how truly exploitative it was. Sorry, but that’s not an excuse.

And why didn’t she know she was exploiting poor women of color in the third world? Because of her “white privilege” that blinded her to the reality of what she was doing. The irony is that her desire to turn her birth junkie hobby into a money making exercise (“birth junkie privilege”) blinds her to the fact that homebirth midwives are exploiting white women in the first world, and in exactly the same ways.

I’ve taken Gordon’s excuses and just changed a few words to illustrate how homebirth midwives exploit privileged Western white women.

Consider:

It is Wendy’s birth junkie privilege that says a homebirth advocate’s story — even when it remains untold — is always more believable than the obstetrician …

It is Wendy’s birth junkie privilege that helps her to believe that women need homebirth midwives more than homebirth midwives need clients …

It is Wendy’s birth junkie privilege that says that the tone used by obstetricians is offensive (“My OB Said What??!!”), so she can dismiss what they’ve said …

It is Wendy’s birth junkie privilege that says that her beliefs about what is unethical trump those of doctors and medical ethicists .., while the ethical concerns of the babies and mothers being harmed by homebirth midwives are not addressed at all.

It is Wendy’s birth junkie privilege that says that homebirth midwives get to decide what and who is to be believed. Hence the deleting and banning of dissenting opinions or even actual facts from every homebirth website, blog or message board.

It is Wendy’s birth junkie privilege that makes her believe that her truth is The REAL Truth … and that anyone who disagrees should “educate” herself

It is Wendy’s birth junkie privilege that permits her to think that she gets to determine when REAL harm is done … Hence the rallies to support homebirth midwives who have presided over deaths instead of investigations into their conduct.

It is Wendy’s birth junkie privilege that tells her that there will be no consequences to sweeping aside the voices of homebirth loss mothers who express that harm is being done to them …

It is Wendy’s birth junkie privilege that allows her to decide who, if anyone, she will be accountable to, which generally means no one … Hence the refusal of MANA, her organization, to release their own death rates.

And my personal favorites:

It is birth junkie privilege that permits homebirth organizations like Wendy’s organization, MANA, to silence dissent by deleting curious questions from their Facebook page; … to keep recruiting and pretend as if there is “nothing to see here” while sending out a newsletters that makes no mention of the issue at hand.

It is birth junkie privilege that refuses to examine the possibility of another version of the truth other than her own; that will actually lash out at those who dare to speak up about scientific evidence and turn the tables back on them, making herself and her colleagues out to be the real victims. It is birth junkie privilege that says that the real damage done here is to the good reputations of the homebirth midwives, and that this concern for the reputation of homebirth midwives supersedes the harms being done in communities where homebirth midwives practice.

Birth junkie privilege assures Wendy that there will be no adverse impact to homebirth midwives if they just walk away from deaths and injuries at their hands. The folks at MANA (Melissa Cheyney, Geradine Simkins and Wendy Gordon among others) just continue to wave their hands, avoid the conversation with the community, and hope that this blows over quickly so that they can all just get back to making their money. It is certainly uncomfortable to have to think about the complexity of this and the deeper training issues that need to be addressed within homebirth midwifery …

And when Wendy and her colleagues exercise that ability to turn their backs and walk away without consequence, to go back to their daily struggles that are already hard enough, and leave this mess for someone else to sort out, then we have opted to once again leave their patients to bear the brunt of their profession’s problems. When MANA is not only allowed to be completely unaccountable to the communities that they purport to serve, but are openly bullying them in front of the professional leadership for speaking about being harmed (or holding “human rights” conferences to whine that homebirth midwives are persecuted), they highlight a major, major problem for the entire homebirth midwifery community.

Wendy Gordon willingly exploited women poor women of color in the third world to benefit herself. She says she’s sorry and she didn’t understand, but I don’t see her making any effort to provide restitution to the women she used and may have harmed.

In fact, what I see is a woman willing to say “sorry” when she’s wrung what she needed from poor women of color in the third world, then pivot on a dime to exploit well-off white women in first world countries to wring the money and the prestige that she wants out of them. No doubt she’ll say she’s sorry when MANA is forced to acknowledge that they’ve hidden their death rates all along, and the CPM is abolished. In the meantime she’ll take what she wants and ignore those she harms. I wonder if she’ll eventually blame it on her birth junkie privilege.

Proponents of “alternative” medicine often disagree profoundly on treatment methods. Sick? In pain? Try this homeopathic remedy that contains no active ingredients. Stick needles into acupressure points. Wear magnetic foot pads to pull the toxins out of your body.

But on one point all proponents of alternative medicine agree. Since the source of all your troubles is a weak immune system, the key to treating and preventing all illness is “strengthening the immune system.” Indeed, this belief is so widespread, it appears that the only people who don’t subscribe to it are people who actually know something about the immune system, doctors, immunologists, microbiologists, etc. The idea that disease can be treated and prevented by “strengthening the immune system” depends on a profoundly flawed, almost cartoon like, view of the immune system itself.

The immune system is tremendously complicated, involving as it does innate cellular immunity and humoral (antibody) immunity. Multiple poorly understood organs make up the immune system. Anyone actually know what the spleen is for? And how about lymph nodes and bone marrow? Those are also quite complex. It is the interactions of these types of immunity, within the various organs of the immune system and throughout the body that determine whether and how we can fight off disease.

The alternative medicine view of the immune system is cartoon like in its simplicity. The individual components of the system, and their specific functions are never discussed or even mentioned. Too complicated. The cascade of events that occurs when the body’s outer defenses of skin or other tissues are penetrated by a foreign substance is completely ignored. Also, too complicated.

Instead, the immune system is conceptualized as a unitary entity that it either weak or strong. If you get sick, your immune system must be weak. In order to prevent illness, or to treat it once it occurs, you must “strengthen” your immune system. And how do you do that? The way you do everything in alternative medicine: you eat the right foods, and take vitamins and supplements.

But, of course, illness is not caused by a weak immune system. The specific mechanisms of illness depend on the specific causes. One possible cause is a failure of innate cellular immunity to find and destroy bacteria that penetrate the barrier of the skin. Another possible cause is the inability of the humoral (antibody) system to create antibody fast enough to overwhelm a viral invader. Instead, the invader gets a tremendous head start before the body can fight back and the virus overwhelms the host. Yet another factor is the presence or absence of various immune system organs. For example, it is well known that removal of the spleen leaves people particularly vulnerable to infection by the pneumococcus bacteria.

In every case, the disease results from a complex interaction between the disease causing agent and a specific component of the immune system. Moreover, there is no evidence that nutrition, vitamins or supplements can do anything to change the balance in these interactions, since the fundamental problem is not malnutrition, or vitamin or mineral deficiency.

It’s not as though we don’t know what a truly weakened immune system looks like. Chemotherapy (which preferentially kills fast growing cells) and certain disease like AIDS, knock out one or more components of the immune system, rendering people more susceptible to disease. If enough of the immune system is compromised or destroyed, the individual becomes vulnerable to infections that would otherwise be harmless or never occur in the first place.

In addition to ignoring what a weakened immune system looks like, and imagining that nutrition is the source of “strength” of the immune system, advocates of alternative medicine have another naïve belief about the immune system. They appear to think that the immune system can be overwhelmed by too much information. Ignoring the fact that each individual faces hundreds, thousands or more immune challenges each day, alternative medicine afficianados argue that vaccines, particularly those designed to immunize against more than one disease at a time, “overwhelm” the immune system, particularly what they imagine to be the “underdeveloped” immune system of small children.

Ironically, the truth is exactly the opposite. Vaccines are one of the few things, if not the only thing, that can strengthen the immune system by giving it a head start against a microscopic invader. Humoral (antibody) immunity takes time to ramp up if the body has never seen the invader before. It’s as if the body can’t start making weapons until it has already been invaded. Vaccines act like a picture of the enemy. Vaccines allow the body to “see” what the invader looks like before the invasion, and to stockpile weapons for the coming fight. When the assault ultimately occurs (when the person is exposed to the disease), the counterattack can begin without delay, and therefore it is much more likely to be successful.

As a general matter, a detailed understanding of system function is not necessary for lay people to understand what the system does. People do not need to know about all the different clotting factors to understand that blood should clot when you are cut and that something is wrong if it doesn’t clot. No one would invoke the idea of a “weak” clotting system to explain why a hemophiliac is bleeding to death, and no one would recommend eating the right foods, or taking vitamins or supplements to treat hemophilia.

Ordinarily, a detailed understanding of immune system function would not be necessary for lay people to understand what the system does. Unfortunately, a detailed understanding of the immune system has been replaced with a cartoon like caricature of the immune system, leading lay people to believe that it is either weak or strong, and that it can be strengthened by eating right. It is this cartoon like view that makes lay people vulnerable to the claims of alternative medicine practitioners and, therefore, this cartoon like view must be changed.

This piece first appeared in December 2009.

On the face of it, suspicion of vaccines is incomprehensible. Vaccination has been one of the biggest lifesavers of the past 200 years. It is the cornerstone of public health, directly responsible for the dramatic drop in infant and child mortality and the dramatic extension of lifespan we have enjoyed over the last century. Despite countless conspiracy theories advanced by vaccine rejectionists in the past 200 years, not a single one has turned out to be true.

True, there are side effects, some serious. However, serious vaccine side effects like brain damage or death are so rare as to be measured per 100,000 people or per 1,000,000 people. There has been no effort to hide these serious side effects. Indeed parents are required to sign consent forms acknowledging the risk of serious side effects, including brain damage and death, before their children can be vaccinated.

So why are people suspicious of vaccines? There are many reasons including the American love for conspiracy theories, the public campaigns led by prominent celebrities, and the desire to assign causes to diseases like autism where the cause remains unknown. The most important cause of the suspicions, though, is one that is very easy to address. Most people don’t know how vaccines work.

To understand how vaccines work, you need to understand how the body defends itself from bacteria and viruses. Just like the body has a dedicated system to digest food (the gastrointestinal tract) or to remove waste products (the kidneys and urinary tract), the body also has a dedicated system to fend off bacteria and viruses; it’s called the immune system.

The body actually has three layers of defense against bacteria and viruses. The first is the physical barrier presented by the skin or the lining (mucous membranes) of interior passages like the mouth and nose. Although we are surrounded at all times by bacteria and viruses, most of them never make it beyond the skin. Of course the integrity of the skin and mucous membranes can be disrupted by a cut or puncture, allowing bacteria or viruses to be introduced directly into the body.

The second line of defense is a non-specific immune response. If bacteria colonize a cut on your hand, your body reacts in a predictable way. There will be swelling, redness, and pain, a response that does not depend on the identity of the threat. Special immune cells will race to the site and engulf the offending bacteria. When they die in the attempt, they accumulate as pus.

Even primitive animals have non-specific immune responses, but higher animals and human beings have an additional, more powerful response. We can produce antibodies. Antibodies are proteins that recognize specific bacteria or viruses and bind to them, thereby signaling to other immune cells that they are targets for swift neutralization. Each antibody binds to a specific site on a specific bacteria or virus.

We’re not born with those antibodies, though. We make them in response to a threat. For example, we are not born with antibodies to the chickenpox (varicella) virus. When exposed to the varicella virus, though, we can learn to make antibodies to it. It takes time, but gradually we can produce enough antibodies to fend off the disease.

Unfortunately, we don’t always get the time we need. We can make antibodies to smallpox, for example, but many individuals are overwhelmed and killed by the virus long before they could make enough antibodies to fend it off. Those who do win the race and manage to produce enough antibodies to survive are now permanently protected. That’s because the immune system retains the ability to make the specific antibodies against the smallpox virus. Whereas it may take days to produce smallpox antibody when first exposed, a second exposure will be met with rapid and massive production of antibody, generally preventing the individual from getting sick at all.

So in order to be protected from the disease, you had to get the disease, and you might die before you were able to make enough antibody to protect yourself. Imagine, though, if you could learn to make the protective antibodies without actually getting sick. That’s the theory behind vaccines.

In order to make antibodies to a virus (or bacterium) the body needs to “see” the virus. In other words, it needs to have direct exposure to the virus, but that virus doesn’t have to be functional, and it doesn’t even have to be whole. A virus can be inactivated (live attenuated) or killed and still produce an immune response. It can also be broken down into its constituent parts and the parts can produce an immune response. Any future exposure to the live virus (though contact with others who have the disease) will be met with rapid and massive production of antibody, preventing the individual from getting sick at all. A vaccine is merely an inactivated or dead form of the virus, letting you learn to make antibody without getting sick in the process.

Vaccines do not produce perfect immunity. The dangerous part of the virus might be the part that evokes the most powerful immune response. Rendering the virus harmless by inactivating it, killing it or breaking it up, may remove that part and the immune response to the less dangerous parts might be weaker. So actually getting the disease may produce a better immune response than the vaccine … but only if you survive the disease.

Successfully fighting off a disease depends on being able to produce enough antibody before the disease kills you. Until vaccines, the only way you could learn to produce antibody was to actually get the disease. Now, instead, you can learn to make antibody by being exposed to a harmless form of the virus or bacterium.

This piece first appeared in October 2009.

I want to have Emily Oster’s publicist. Oster, an economist, recently published the book Expecting Better: Why the Conventional Pregnancy Wisdom Is Wrong-and What You Really Need to Know. Her book has been publicized everywhere, a tribute to her media connections (she has written for The Wall Street Journal) and superb public relations.

I haven’t read the book, yet, but I have been reading Oster’s columns in the online magazine Slate, and have found them to be a somewhat misleading. There are no factual errors, but, as might be expected for an economist writing about obstetrics, she has no clinical judgment, and that dramatically undermines the quality of her advice.

Today’s piece, The Best Method for Getting Pregnant is a good example. Here’s what Oster has to say:

So, how big a deal is it to detect ovulation? Answer: It matters. From very detailed data on couples—including exactly when they had sex and whether they conceived—we know that pregnancy is only possible in the five or six days leading up to and including ovulation. This suggests that you’ve got to get the timing right, and if you do, the odds are pretty good. Pregnancy rates are 30 percent for sex on the day before or day of ovulation, versus 10 percent five days before. No one in the aforementioned study got pregnant having sex more than five days before ovulation.

So should you lay back and leave your pregnancy to chance, or track, measure, and chart? Depends on your time frame, I suppose. But done right, if you want to have the best shot at getting pregnant, shell out for the pee sticks.

Not exactly.

Oster makes a major assumption, one that is untrue. Oster appears to believe that the reason women don’t get pregnant the first month that they try is because they haven’t timed sex to ovulation. That’s wrong. The main reason women don’t get pregnant each month they are trying has nothing to do with ovulation and everything to do with whether the fertilized egg divides properly, implants properly and grows properly.

As a general matter:

50% of women will get pregnant in 4 months of trying
75% will get pregnant in 8 months
90+% will be pregnant within one year

Why doesn’t every woman get pregnant in the first month she tries? Because of the massive wastage inherent in reproduction.

Every woman is born with millions of eggs and each man produces trillions of sperm during a lifetime. Most are never even used. Even when the conditions are right for pregnancy (a sperm meets an ovum) many things can and do go wrong. The ovum could be abnormal, either in function or in its genes, the sperm could be abnormal, either in function or in its genes, or the combination could be genetically abnormal. In any of these cases, the fertilized ovum could fail to divide.

It is possible for the fertilized ovum to divide into the ball of cells known as the blastocyst, but when it gets to the uterus, it fails to implant properly. Or the blastocyst implants, but it dies and is washed out with a menstrual cycle. Or it starts growing and the woman misses her period (and may even have a positive pregnancy test), but then it dies. In that case, she would get her period a few days late. That’s known as a “chemical pregnancy,” meaning a pregnancy that grows to the stage where it releases a tiny amount of pregnancy hormone into the mother’s bloodstream (hence the positive pregnancy test), and then dies.

That doesn’t even take into account that 20% of well established pregnancies will grow for several weeks and then die, resulting in a miscarriage.

So while Oster is technically correct that ovulation predictor kits are the best method for predicting ovulation, she misses two larger points:

1. The timing of sex is rarely the reason why a woman doesn’t get pregnant in a month that she is trying to get pregnant.
2. For women who ovulate regularly, the majority of women, ovulation reliably occurs approximately 14 days before the next period is expected.

Ironically, Oster’s fundamental error, the belief that it is the timing of sex is the reason why a woman doesn’t get pregnant within the first month of trying, is exactly the type of conventional wisdom that she claims she will debunk. But because she fell for the conventional wisdom about fertility, Oster is not reducing anxiety for women, ostensibly the primary motivation for her book; she is raising anxiety. And it points out a fundamental flaw with Oster’s data driven approach.

As anyone who reads this blog knows, I am totally committed to the use of data in making decisions about pregnancy, but data without both a strong foundation in human physiology and excellent clinical judgment can lead people like Oster to make misleading recommendations.

Pregnancy is not a project, requiring micromanagement in order for it to successfully produce a live, healthy baby. Beyond high quality prenatal care, a few basic restrictions (no smoking, no recreational drugs, among others), and hospital birth, there is really not much a woman needs to do, or can do, to reliably produce a healthy baby exactly when she wants one.

What’s the best method for getting pregnant? Have sex regularly, or if not regularly, within the 14-19 days prior to the next expected menstrual period. That’s it.

And if you don’t get pregnant the first month, there is NO NEED to do, or buy or chart anything. Just try again.

The good news is that homebirth midwives are beginning to recognize that being an “expert in normal birth” is meaningless. Any taxi driver can preside over an uncomplicated birth. Women hire birth attendants to prevent, diagnose and manage complications and homebirth midwives have zero experience with that.

The bad news is that homebirth midwives are trying to get that experience by exploiting poor women of color in the developing world.

That’s the explosive charge leveled at Midwife International by The Alliance for Ethical Midwifery Training.

What is Midwife International?

According to its website:

More than 58 countries lack enough qualified midwives to provide timely access to skilled healthcare for mothers and infants. Our solution is to train midwives who are equipped to work in resource-constrained regions where maternal and child mortality is high and the need for professional midwives is greatest.

Not exactly. Midwife International is a midwifery school, charging exorbitant tuition, using poor women of color as a source of complicated cases, and providing nothing in return.

For this privilege, American students are charged $19,000/yr, PLUS books, supplies, travel, insurance, accommodations, and living expenses.

Midwife International managed to corral a who’s who of American homebirth midwifery into supporting this scheme. Board members included Aviva Romm, MD, Jan Tritten, the editor of Midwifery Today, and Robbie Davis-Floyd, among others.

But, according to The Alliance for Ethical Midwifery Training:

The communities MI claimed to be serving were exploited for the benefit of the MI students and the considerable profit of MI, furthermore, host sites and local midwives were taken advantage of and at times blackmailed into compliance.

How?

… MI is alleged to have:

• Used bribery to undermine the host site Directors and their programs and to de-stabilize the local programs and clinics:
• Taken back much need supplies and equipment if the host site Director would not comply with MI’s demands;
• Negotiated secret agreements with host site midwives to give priority to MI students (many of whom are in the first steps of early midwifery training and whose skill level, in some cases, could best be described as elementary) over their own indigenous midwives who are being trained to meet the ICM Millennium skill goals; and
• Not compensated host sites at the rate initially negotiated, nor reimbursed host sites for modifications made to their programs and sites in order to accommodate the MI program. In addition, the demands made by MI for accommodations and life style issue for the students and preceptors were unreasonable given the realities of the countries in which the MI students and preceptor would be living.

The website contains testimonials from the women who run the clinics for the underserved and they make for very disturbing reading.

The Alliance identifies the key problem with first world laypeople learning midwifery on third world women:

There is a structural violence that occurs when a person from the west attempts to learn on those who have less power and privilege than they do. There is a long history of exploitation of Black and Brown bodies for the purpose of western power and gain. There is also a long history, even within midwifery, of silencing those who speak out about these issues. What has happened here is that an institution has been built based on each of these acts of violence. We refuse to be silenced. We stand together to share the stories of what has occurred…

The behavior of Midwife International, if true, is starkly reminiscent of the behavior of Big Pharma. The rules and regulations for testing new medications on people from industrialized countries are onerous and expensive because the governments of those countries want to protect their citizens from exploitation. The same protections do not exist in many countries of the developing world, so pharmaceutical companies often test their products there.

Similarly, the rules and regulations for midwifery training in first world countries are appropriately onerous for a profession responsible for the lives of babies and mothers. Hence, the certified professional midwife credential (CPM) is considered inadequate by ALL first world countries, and CPM trainees are not allowed in hospitals where to gain clinical experience. The same protections do not exist in many countries of the developing world. How much easier, then, to foist uneducated, untrained laypeople on those countries.

In light of these allegations, several board members, including Aviva Romm, MD, have resigned, but one must question their judgment for signing on in the first place (and ask if financial compensation was paid to them for their board positions).

The fundamental ethical question remains, however. Is it ethical for homebirth midwives, who cannot meet the standards for education and training of any industrialized country, to “practice” on poor women of color in developing countries? It could possibly be ethical if proper safeguards were put in place, but it is not clear if homebirth midwives would be allowed to care for poor women of color in developing countries if proper safeguards were put in place.

The bottom line, as always, is that the CPM credential should be abolished. There is no need for a second, inferior class of midwife in the US, and there is certainly no need, or benefit, to a second, inferior class of midwife who learns about pregnancy complications by preying on underserved poor women of color in developing countries.