Jennifer Block made a big mistake this time. No, I don’t mean her habit of offering mistruths, half truths and outright lies, nor her propensity to ignore facts that she doesn’t like, not even her pathetic substitution of ad hominem attacks against me in place of addressing the data that I presented. In her recent Slate piece, she questioned the integrity of another journalist, Michelle Goldberg, and it has blown up in her face.

Block didn’t know about Goldberg what I learned about her. She is the most thorough, in depth reporter I have ever dealt with. She immersed herself in the topic over a period of weeks, interviewed dozens of people and followed up on everything. When I told her about the Johnson and Daviss paper and the bait and switch they perpetrated to make homebirth look safe when their data showed it wasn’t, she called them and offered an opportuntity to explain. Apparently, they weren’t able to explain away the bait and switch.

When I told her about women who lost babies at homebirth, she spoke to nearly a dozen of them. She talked to other obstetricians, a pediatric emergency room chief, and many more people who are directly and indirectly affected by the homebirth issue. The article that she eventually produced only hinted at the tremendous amount of research that went into it, as well as the strenuous efforts to follow through on every claim, and the opportunities given to homebirth advocates to explain their previous actions.

Goldberg draws on this research in a published response to Block’s accusations:

… I’m grateful for Block’s piece, since it gives me a chance to wade into some of the disputes that I elided, for reasons for space and readability, in my original article…

Block presents two arguments for why we shouldn’t take Tuteur seriously. The first is that she is no longer practicing …Block offers no evidence to dispute her interpretation of existing data. Nor does she explain why Tuteur’s retirement renders her impressive medical background irrelevant.

It was Tuteur who found serious flaws in a widely-cited study published by home-birth advocates Kenneth C. Johnson and his wife, Betty-Anne Daviss, in the British Medical Journal, that purported to show home birth’s safety. In response, Johnson and Daviss self-published a new analysis with updated data—a tacit admission that Tuteur’s criticisms were valid. (Tuteur, as I explained, disputes the methodology of their new, non-peer reviewed analysis as well.) She is an important voice in this debate, whether Block likes it or not.

Moreover:

… I also quoted Martha Reilly, chief of Women’s and Children’s Services at McKenzie-Willamette Medical Center near Eugene, Ore., a place where home birth is particularly popular. Reilly told me that every ob-gyn she works with has treated a woman rushed in after a home birth gone awry, her baby dead or severely injured. Block essentially accuses her of lying, though according to Reilly she didn’t bother to call her. “The Department of Health reports 102 planned home births in Lane County in 2010,” writes Block. “Reilly’s claim is improbable given that the odds are in the per-thousand range, though it’s perhaps indicative of how polarized some providers are on this issue.” But Reilly didn’t claim that all these disasters happened in one year. Nor is there any reason to assume, as Block does, that none of them came from surrounding counties.

And typical of Block’s “bad faith approach”:

… She quotes one “Melissa Cheney,” an “anthropologist at Oregon State,” who claims to have found that doctors spread unsubstantiated rumors about home-birth deaths. In fact, the anthropologist’s name is spelled Melissa Cheyney, and in addition to her post at Oregon State, she is a licensed midwife and head of the division of research at the Midwives Alliance of North America. Cheyney is a major figure in the pro-midwifery community, not an objective academic observer.

In addition:

…[Block] cites studies from Canada, the U.K., and the Netherlands … I explained, in my original piece, why it doesn’t make sense to compare home-birth midwifery in the United States, where training and regulation are incredibly lax, to the practice in countries where it’s deeply integrated into national health services. For the sake of brevity, I didn’t go into detail. Let me do so now, focusing on Holland, a country American home-birth advocates love to reference. (You may also want to read Lindsay Beyerstein of In These Times on the same subject.)

… [I]t’s not entirely clear just how well the Dutch system really works. A 2010 study of Holland from the British Medical Journal found that the babies of low-risk mothers cared for by midwives had a higher death rate than the babies of high-risk women who delivered in hospitals. The study also pointed out that the Netherlands has one of the highest perinatal morality rates in Europe. “Whether the Dutch obstetric-care system contributes to this relatively high mortality remains unclear,” it says.

Goldberg offers a powerful indictment of homebirth advocates:

… The home-birth movement seems to be driven by a quasi-religious naturalist ideology that denies the danger that’s been inherent in childbirth for most of human history. It cherry-picks studies, distorts facts, and attacks its critics in a way that reminds me of my many years reporting on the Christian right. (my emphasis)

As to the charge that those who report on the data about the risk of neonatal death at homebirth:

Women have a right to adhere to the home birth movement’s ideology, and as far as I’m concerned they have a right to have their babies anywhere they choose. But they also have a right to know that giving birth at home has the potential for as much danger and trauma as anything in Block’s book about the horrors of hospitals. They have a right to weigh the very real risk of an unnecessary C-section against the risk of a dead baby, which is much smaller but, to many mothers, much more grave.

That’s not trying to scare women. It’s being honest with them.

They must be really frightened. They’ve rolled out the big guns.

After years of advising each other “Don’t listen to Dr, Amy,” they’ve turned to advising the general public not to listen to me. How else to explain Jennifer Blocks’s charming collection of ad hominems masquerading as an article of Slate. Entitled How to Scare Women, the piece carries the subtitle “Did a Daily Beast story on the dangers of home birth rely too heavily on the views of one activist?”

The piece in The Daily Beast to which Block refers is Home Birth: Increasingly Popular but Dangerous, which included the latest statistics of homebirth deaths as well as stories of two terrible, senseless, entirely preventable deaths. Block more or less dismisses the stories, but doesn’t even bother to dismiss the statistics. She can’t; they’re accurate and damning as she surely knows. So instead she tries to discredit me in the hope that she can divert the attention of homebirth advocates from the data itself. It’s a pretty despicable tactic, especially when you consider that it depends on the belief/hope that homebirth advocates are so gullible and unsophisticated that they cannot tell them difference between the two.

Fortunately, it addition rehearsing the same old ad hominems that are so silly that I have been satirizing them for years (She let her license lapse! She quite writing for Science Based Medicine!), Block helpfully links to a variety of blog posts that I have written. I’m not sure why she did it, because it thoroughly undercuts her efforts to discredit me by giving readers access to what I have actually written. I’m not sure whether she thinks less of me or her readers; me because she doesn’t find the pieces persuasive or her readers because she assumes that they won’t read them, understand them, and be convinced by them.

I left a comment on the post:

I suppose I should be flattered that Ms. Block believes that women decide whether or not homebirth is safe depends on what they think about me. I, on the other hand, feel very strongly that women are capable of looking at data and scientific evidence for themselves and my chief task is simply to make it accessible to them.

If you get past the various ad hominem attacks on me, you may note that Ms. Block has not challenged the fact that the latest CDC data shows that homebirth with a non-nurse midwife has a mortality rate 600% higher than comparable risk hospital birth. She has not challenged the high and rising rate of perinatal death at planned homebirths attended by licensed homebirths, rates that are double or triple the rate for Colorado as a whole, including premature babies and high risk women.

Women have a right to give birth at home, but they can’t make an informed decision if they don’t have complete and accurate information. Ms. Block is welcome to continue to write about me; I’ll keep writing about the data and I’ll keep trusting women to decide for themselves how to act on that data.

Jennifer Block and I do agree on one thing however; the article in The Daily Beast is scary. The scary part, though, is the mass of data that shows that homebirth with a non-nurse midwife dramatically increases the risk of neonatal death. It is deeply unfortunate, that Block, like most professional homebirth advocates, chooses to ignore that data and resorts to what amounts to little more than name calling in attempt to get others to ignore it as well.

I have a suggestion for how we might resolve the impasse. I have repeatedly challenged Jennifer Block to publicly debate the safery of homebirth. Slate could serve as the forum for a print debate about the state, national, and international statistics on homebirth, and the growing body of scientific evidence. Would the folks at Slate be willing? How about it, Jennifer? I’m ready any time; how about you?

Janet Fraser, the leading Australian exponent of unassisted childbirth lost one of her own children at homebirth. You might be excused for thinking that this the death of one of her own children is the most traumatic loss that Fraser has experienced, but you’d be wrong. According to Fraser, she was more traumatized by the loss of her ideal birth “experience” when her healthy first child was born. Apparently, the coroner didn’t see it that way. Indeed, the brief coronial report exoriates Fraser for her fantastical beliefs and her chilling narcissism.

The report summarizes what happened:

1. This is an inquest into the death of Roisin Fraser who was born and, within minutes, died on 27 March, 2009. Roisin was the daughter of Janet Fraser and Trevor George Stokes. There are two older children of that relationship, still living with their mother. Ms. Fraser is a leading tigure in a movement called “Joyous Birth” advocating free birthing which is a method of home birthing where, except in circumstances of quite dire emergency (and, sometimes, even in those circumstances.) the intervention of medical practitioners, nurses and hospitals and, often, as in Roisin’s case, that of midwives is avoided.

Cause of Death

2. Practicing free birthing principles and with the assistance of her partner, Trevor Stokes, and a friend, Marianna Duce, both unqualiied in medicine, nursing or midwifery, Janet Fraser was delivered of Roisin at her home at about 1.12am on 27 March, 2009. Roisin was pronounced dead at Royal Prince Alfred Hospital, Camperdown at about 2.27am on the same day.

Why did Roisin die? The coroner, Scott Mitchell, found:

Roisin Fraser, who was born on 21 March, 2009, died moments later at her parents then home at … NSW of an hypoxic episode probably a direct or indirect consequence of cord entanglement encountered during delivery where, at her mother’s insistence, mother and chlld were unassisted by any person qualified ln the areas of medicine, nursing or midwifery.

In practical terms, Roison Fraser died because of the inability of Fraser’s attendants and Fraser herself to resuscitate the baby:

Essentially, Ms. Fraser was quite unprepared for what happened. There was not even a hard, flat surface available on which Roisin could be placed for resuscitation so these three amateurs – Ms. Fraser, Mr. Stokes and Ms. Duce, first placed the child on the rim of the inflatable pool and, when that proved unsatisfactory, used a chair. They were unable to abandon the chair and place Roisin on the floor in order effectively to administer CPR there because, the placenta not having been delivered, “that was as far as she would reach. ” Evidently, it occurred to nobody present to clamp and cut the cord and, anyway, Ms. Duce told the inquest, she had not been aware of the ready availability of any equipment to enable her to do so. According to Ms. Duce, further difficulties were encountered in administering CPR because Roisin was slippery and difhcult to hold and, evidently, it did not occur to anybody to wrap her in a towel although there were towels nearby.

But the real reason for Roison’s deaths was Janet Fraser’s personal beliefs:

The Joyous Birth website controlled by Ms. Fraser offers advice to expecting or expectant mothers some of which is couched in temrs which even Ms. Fraser, its principle author, described as “intemperate.” Visitors to the site are warned ofa “giant birthing industry” against which Ms. Fraser has dared to pit “her arrogant feminine self” “Hospitals are dangerous” and “Obstetricians” she wams “are surgeons at heart
..whose skill set is rarely needed.” Mothers to be are advised that ‘size estimates are a crock” and that “your pelvis works perfectly.” “Monitoring” is described as “you with a bed strapped to your back, monitors wrapped around your be/LY, probably a scalp monitor shoved through your vagina and screwed into your baby’s head thus preventing you from moving around and actually birthing.” Women are warned that their obstetrician is liable to “manoeuvre” them into surgery when they really don’t need it- “there’s a basic contradiction in going to a surgeon to avoid surgery isn’t there?” which, they are reminded, will ‘guarantee your uterus has more than a hole, it will have a big slice that someone will put their hands in and rip open.”

According to Ms. Fraser as she is reported on the Joyous Birth website, “hospitals (places for sick people) have no business dealing with nonnal, physiological birth (perfonned by healthy women) but now that they do, they continue to peddle their own importance and kid us that we need them… …Surgeons create repeat business for themselves in a way that, if it was another industry, would be seen for what it was –
shameless money making… …So it doesn’t matter if she looks for another surgeon or hospital (they’re run by surgeons, did you realise that?”

The coroner explains:

This propaganda served up by Joyous Birth, of which the foregoing is only a taste, appears typical of an intention to convert women who visit the site to the view that medical and hospital involvement in their pregnancies and births is undesirable and contrary to their interests as women and mothers and that professional involvement, including the involvement of professional midwifes, should be kept to a minimum.

The coroner concludes:

This is a free country and Ms. Fraser can use the Joyous Birth website to proselytise as she sees fit… [Her views] are wrong views, extravagantly expressed and quite insensitive to the harm they may do to others, whether inexperienced mothers or children like Roisin whose chance of life was so unnecessarily put at risk. lf they seem intellectually valid or politically attractive to Ms. Fraser, she might give thought or more thought to the effect they may well have on children like Roisin.

Ever wonder why your pelvic and abdominal organs don’t simply fall out? Probably not, but if you did stop to wonder about it, you might have concluded that it is the bones of the pelvis that keep everything inside. That’s only part of the answer. In fact, the main structure that keeps everything inside is the pelvic floor.

The pelvic floor is the name for the group of muscles that overlap each other across the bottom of the pelvis. It acts like a hammock to suspend the pelvic organs and hold them in place. The pelvic floor looks like this:

Just like a hammock, it can become torn, stretched and worn. In fact, it can become so torn, stretch or worn that the pelvic organs do begin to fall out. That is known as prolapse.

What is prolapse? Why does it happen? How is it related to childbirth? And how do tears of the pelvic floor compare to and impact prolapse? To answer these questions, it helps to visualize the pelvic floor as a hammock made of spandex fabric, rather like the hammock in the photo above. Now imagine that the hammock has two small holes in it to let the rain flow and the leaves fall through. Two relatively small holes won’t compromise the strength of the hammock.

What happens in pregnancy and childbirth? Pregnancy is the equivalent of a great weight on the hammock for a prolonged period of time. It is easy to see how that could stretch the hammock. Perhaps the fabric will return to its original shape and size, but if you leave the weight on the fabric long enough, or repeat the application of weight for long periods many times, the fabric will ultimately stretch and may not completely return to the previous shape. That’s similar to the impact that pregnancy has on the pelvic floor.

How about childbirth? Imagine that a bowling ball is forced through one of the small holes in the hammock. A number of things may happen. The fabric may be stretchy enough to accommodate the bowling ball and to return to its original shape after the bowling ball passes through. It’s also possible that the bowling ball will pass through, but the hole is permanently stretch. That’s equivalent to a larger vaginal opening after childbirth. Finally, imagine that in order for the bowling ball to pass through, the fabric tears. That’s the equivalent of a vaginal tear. The opening is now permanently larger. A small vaginal tear may heal on it’s own, but if enough tissue is torn, it may not heal back together properly and the woman will be left with a gaping vagina.

A fourth degree vaginal tear is the equivalent of a tear in one hole of the hammock extending all the way into the second hole, leaving a big rent in the fabric. That will never heal by itself, and, it will leave the woman with bowel incontinence.

What about prolapse?

Prolapse is different but related.

Imagine that the hammock is used for the next twenty five years. It is almost inevitable that the fabric will get stretch and worn. The holes in the fabric, whether they are still in orignal shape, already permanently stretch, or actually torn, will widen still further. The same thing happens in the pelvic floor and the process accelerates as estrogen drops and disappears in menopause. Now the pelvic organs may begin to literally fall out.

When the bladder falls out (prolapses), it is called a cystocele. When the uterus false out it is known as uterine prolapse. Since the bladder is so close to the uterus, when the uterus falls out the bladder usually comes down with it. In either case, when the bladder begins to fall through the pelvic opening, women can lose control of their bladder. This kind of incontinence is known as stress urinary incontinence (SUI). Things are usually okay in most circumstances, but when a woman coughs, sneezes or laughs, intra-abdominal pressure is increased and the bladder is pushed through the opening in the pelvic floor and urine is forced out. Stress urinary incontinence is extremely common in women in their 50’s and older.

If the rectum falls out, it is called a rectocele, and it can affect bowel continence.

What’s the relationship between tears and prolapse? It’s easy to envision that if the opening in the pelvic floor is already stretched or torn to larger than original dimensions, the stretch and wear of age is only going to make the problem worse. That’s why vaginal birth puts a woman at much greater risk of prolapse. Having a C-section instead of a vaginal delivery does not guarantee that you will not ultimately develop a prolapse of one form or other. After all, simply being pregnant can permanent wear the muscles of the pelvic floor. However, vaginal delivery adds additional stretching, and possibly tearing to what would have happened anyway, making prolapse much more likely.

This explains the original impetus for episiotomy. Until the past few decades, there was not much that could be done for prolapse so doing anything possible to avoid it seemed like a good idea. The thinking behind episiotomy was to cut a straight “tear” before the muscles of the pelvic floor were stretched to their maximum and before they tore of their own accord. Unfortunately, in practice it did not work that way. Rather than protecting the muscles of the pelvic floor, the most common type of episiotomy (median episiotomy) actually made more extensive damage more likely. Hence the practice of episiotomy has been largely discarded. However, the idea was not a foolish one, and was worth trying.

Obviously this is a vastly simplified view of a complex anatomical issue, but hopefully it will help readers to better understand tears and prolapse, why they occur, and their ultimate consequences.

I’ve written before about homebirth midwives who don’t know how to suture and therefore tell women with serious perineal tears that they don’t need stitches. Here is an example of the terrible result:

I gave birth at home to a beautiful and healthy 8 pound 4 oz baby in Feb. 2012… After birth I had fecal incontinence (gas) but thought it was really because of the stretching of the muscles after birth. Right after birth my two midwives checked me and said it was just 2nd degree lacerations and that I was ok, no need to stitch, just keep my legs together and it will heal by itself.

As I’ve explained previously, major perineal tears will not heal by themselves:

A torn sphincter will not heal itself because the torn ends are usually far apart from each other after the muscle fibers retract. The superficial layers of the tear will heal and it may look like everything is normal, but the woman will not be able to control her bowel function and will definitely need an involved surgical repair under anesthesia.

The story continues:

Four months later, I went to the OBGYN because I thought there was something wrong with me. The opening was just too big and literally I dont have a perineum.

The obgyn told me I had 4th degree lacerations and I needed a procedure called sphincteroplasty and that I would never be able to have any babies vaginally any more. I left the office crying hysterically and called my midwife. I told her that didn’t sound right and she agreed, that Dr. must’ve been wrong. My midwife referred me to another MD, that was midwife friendly.

But the result was the same:

I visit the referred MD and he agrees that I need a sphincteroplasty and referred a colo-rectal [surgeon]. I go to the colo rectal. Not only I have a 4th degree laceration that needs to be repaired with an sphincteroplasty but also a recto-vaginal fistula. In order to have success in this delicate surgery I need to previously have a colostomy surgery before the sphincteroplasty surgery, to open the colostomy and after to close it in order to divert the feces from the area of the surgery, to avoid infection…

What is a 4th degree perineal tear?

A fourth degree tear extends down from the bottom of the vagina, through the tissue separating the vagina from the rectum, through the sphincter (muscle) that controls bowel continence, right through into the rectum itself. The result is that the vagina and rectum form one continuous space.

Why was suturing absolutely necessary?

… [B]ecause the rectum itself has been torn, the possibility exists that the tear may heal improperly and leave a hole (fistula) between the vagina and rectum with consent leaking of feces from the vagina.

That’s exactly what happened to this unfortunate mother. Now she needs 3 separate surgical procedures: surgery to create a diverting colostomy; surgery to repair the rectum, rectal sphincter, and entire perineum; and surgery to reconnect the colon diverted in the colostomy.

As the mother explains:

Recovery time is 4 months or more depending if there is no complications. My family is all abroad, I am by myself SAHM, I am 29 years old and my baby is 5 months old. I’m not going to be able to take care of him while I’m having all these horrible procedures because my midwife couldn’t identify that I had a 4th degree tearing…

Moreover, all future births will need to be C-sections because a vaginal delivery would destroy the repair.

The mother feels devastated:

I am soo sad and upset, I have been crying for the last week. Every time I see my baby I wonder about the risk of undertaking this type of surgeries… I don’t want to have a colostomy for 2 months. I don’t want a scar in the middle of my stomach. I have never had any kind of surgery. This is all very unnecessary. If she could’ve just identify my 3rd-4 tearing and take me right to the emergency room I wouldn’t be tonight telling you this horror homebirth story.

I was sold on the homebirth movement, not anymore. Go with … a professional that can identify the type of laceration you have, one who can identify emergencies and finally a professional that keeps your perineum intact. Your perineum is important in your reproductive life. I’m so lost.

Babies are not the only ones hurt by homebirth.

Homebirth midwife Evelyn Muhlhan, CNM was suspended as the result of 5 separate homebirth disasters, including a baby who died and Enzo Martinez, a baby rendered permanently brain injured.

Enzo’s parents sued and yesterday were awarded $55 million … from the hospital.

Why the hospital?

It will cost an incredible amount of money to care for Enzo and Muhlhan herself is judgment proof, since she apparently carried no insurance. Hmmm, who else was involved in the case that has lots of money? Ahh, yes, the hospital; Johns Hopkins hospital carries lots of insurance. Let’s sue them. Who’s actually responsible for Enzo’s brain injury? Who cares?

Enzo’s case was detailed in the suspension order issued by the Maryland Board of Nursing:

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

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

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

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

In other words, Muhlhan was horribly negligent in caring for this women and the hospital saved Enzo’s life. Enzo’s parents know this and do not dispute it. They insist that the hospital didn’t save Enzo’s life fast enough, contending that there was a delay in performing the necessary C-section.

How did the jury decide that it was a purported delay at the hospital that resulted in Enzo’s injury and not the egregious malpractice of Evelyn Muhlhan? It was easy. Enzo’s parents’ lawyers successfully argued to disallow any evidence of Muhlhan’s negligence.

As the court records show:

Plt [Plaintiff’s] motion in limine to preclude any refence [sic], testimony or argument that ceritified nurse-midwife Evelyn Muhlhan Deviated from the standard of care and to preclude Loraal Patchen, CNM and Carolyn Gegor CNM from testifying is hereby heard and granted.

And:

Plt motion in limine to preclude any reference, testimony and/or evidence of Maryland Board of Nursings’ orer for summary suspension of Nurse-Midwife Evelyn Muhlan is hereby heard and granted.

And just to be on the safe side:

Plt omnibus motion in limine regarding certain irrelevant and prejudicial evidence is hereby heard and agreed upon as it relates to Group B Streptococcus, is agreed upon as it relates to genetic cause of E.M. injuries and is granted as it relates to deviation from standard of care not casually linked to array of harm (episiotomy).

So in a case in which the homebirth midwife violated every standard of care and managed a few creative forms of negligence that haven’t been seen before, including attempting a home induction with pitocin and cutting an episiotomy before the baby’s head was anywhere near delivery, the jury never heard about any of it.

Apparently, as far as the jury knew, Enzo’s mother arrived at the hospital in labor, had a C-section and gave birth to a baby with profound hypoxic ischemic encephalopathy. It could have been (and probably was) the result of multiple hours of labor at home and the egregious malpractice of homebirth midwife Evelyn Muhlhan, subsequently suspended from practicing specifically because of her negligent actions. But the jury was not allow to hear about Muhlhan and her actions. It is hardly surprising, then, that they blamed the hospital.

How did the jury reach this conclusion. As the newspaper article explains:

Donald H. Beskind, a professor at Duke University School of Law … said juries are typically influenced by three main factors when deliberating on malpractice cases: the degree to which it’s clear who was at fault for the negligence, what money would do to improve the plaintiffs’ quality of life, and whether the defense did something to offend the jurors, such as attack the plaintiffs.

It’s pretty clear how the money will help care for Enzo, and we don’t know whether or not the defense did something to offend the jurors. But how on earth was the jury to decide who was at fault when the evidence that Muhlhan was at fault was excluded before the trial even started?

Hospitals and doctors know that when a brain injured child comes to court, sympathy for the child and his parents usually overwhelms any effort to rationally attribute blame. That’s why these cases are typically settled even when the evidence favors the defendant. It’s simply too risky to leave these cases to a jury who may vote with their hearts and not their heads.

Therefore, the fact that the hospital and its insurer went ahead with the trial suggests that they thought not merely that they were not at fault, but that the evidence that they were not at fault was overwhelming. They were wrong and the impact will extend beyond this case:

Stephen L. Snyder, a high-profile Maryland litigator, said the judgment has the potential to further discourage courtroom battles in malpractice cases. Already, most malpractice cases settle before trial, he said.

“If this case is a wake-up call to the hospitals and insurers, they may be more willing to bring closure to cases sooner and more efficiently without marring their reputation, which ultimately would unburden the courts,” Snyder said.

The hospital plans to appeal the verdict, and it may yet be overturned by appeals judges who will consider only the legal issues and the facts of the case.

It is natural to feel sorry for Enzo. He will have to live the rest of his life profoundly disabled because his mother wanted a homebirth.

And it is difficult not to feel sympathy for Enzo’s parents who wake up every day and deal with the catastrophic results of their choice. They need money to care for Enzo.

That may explain why they chose to sue the hospital with deep pockets when it was the malpractice of the negligent homebirth midwife that led to Enzo’s injuries, but that doesn’t make it right.

Reporter Michelle Goldberg has written a terrific piece about homebirth in The Daily Beast, boldly and accurately entitled Home Birth: Increasingly Popular, But Dangerous. It is one of the first (? the only article) to explain how Johnson and Daviss manipulated their data in an effort to hide the fact that homebirth with a certified profession midwife (CPM) in 2000 had nearly triple the neonatal death rate of low risk hospital birth in the same year.

For [homebirth advocates], the gold standard is a 2005 study by Canadian epidemiologist Kenneth C. Johnson and his wife, Betty-Anne Daviss, a well-known home birth midwife…

But Tuteur points out that the figures Johnson and Daviss used for hospital deaths came from studies from the 1970s and 1980s. “They sliced and diced the data to fool people who are not sophisticated,” she says. When she compared Daviss and Johnson’s home birth figures with data on hospital births in 2000 from the National Center for Health Statistics, she found that for women with comparable risks, the perinatal death rate was almost three times higher in home births. That, she says, “is in line with every single other study that’s ever been done of other home birth statistics.”

Goldberg is also notes the appalling homebirth death rate in Colorado,

… one of the few states that mandates the collection of data from licensed home birth midwives. In 2009, midwives performed 637 deliveries, and transferred another 160 patients to the hospital either before or during labor. Altogether, the midwives’ patients suffered 9 perinatal deaths, almost double the perinatal mortality rate for the entire state, including high-risk and premature deliveries. Three of the nine babies died during labor, which is extremely rare in hospital births.

Golberg is referring to the publicly available statistics on the Colorado DORA website. The 2010 statistics (which have not yet been published, in violation of Colorado law) are far worse.

… [T]he perinatal death rate for planned homebirth with a licensed Colorado midwife rose from 11.3/1000 in 2009 to an astounding 16.4/1000 in 2010! Compare that to the overall perinatal mortality rate for the entire state of Colorado (all races, all gestational ages, all pregnancy complications, all pre-existing medical conditions) of 6.3/1000…

It’s easy to understand why Colorado homebirth midwives hid their 2010 statistics; they are an appalling indictment of the midwives and irrefutable evidence that they are unfit and unsafe practitioners.

The Colorado midwives are not alone:

This is the same tactic being employed on the national level by the Midwives Alliance of North America (MANA). MANA collected death rates for the years 2001-2008. While they were collecting the statistics, they publicly promised they would be used to demonstrate the safety of homebirth midwives, but once they saw the results, they decided to hide them instead.

No doubt Goldberg is going to receive a firestorm of criticism from homebirth advocates. I suspect that none of them will be able to rebut the data that she presented, and that is the greatest strength of the piece.

Oh, the irony!

The Childbirth Connection is a lobbying and advocacy organization for the natural childbirth industry. In an ongoing effort to promote the socially constructed values of a small subgroup of women, it publishes papers that purport to show that natural childbirth is supported by the weight of scientific evidence, and is desired by the majority of American women. There’s just one problem; it’s not supported by the weight of scientific evidence and it does not represent the desires and values of American women.

Its widely publicized Listening to Mothers Survey II is a perfect example. The report concludes that obstetric technology is overused, there are too many interventions, there are too many C-sections and women are not appropriately informed of the risks of interventions. Yet the conclusions are completely belied by the evidence in the report.

Mothers generally gave high ratings to the quality of the United States health care system and even higher ratings to the quality of maternity care in the U.S… [M]ost felt that the malpractice environment caused providers to take better care of their patients.

By law … women are entitled to full informed consent or informed refusal before expriencing any test or treatment. Most mothers stated that they had fully understood that they had a right to full and complete information … and to accept or refuse any offered care…

A small proportion of mothers reported experiencing pressure froma health professional to have labor induction (11%), epidural anesthesia (7%) and cesarean section (9%)… Despite the very broad array of interventions presented and experienced … just a small proportion (10%) had refused anything …

The Childbirth Connection wrote a report about listening to mothers, and then proceeded to ignore that mothers were pleased with American obstetric care.

Why did they ignore their own evidence? They ignored it because it did not match the predetermined conclusion that the socially constructed values of the natural childbirth industry represent the “ideal” way to give birth.It’s worth reading the report as an object lesson in the ways in which childbirth organizations misuse, misrepresent and ignore data to serve their own ends.

As usual, they start with the conclusions and work backward. As usual, they present no evidence to support their claims. Here are three specific examples of the way in which the Childbirth Connection attempts to pass off personal opinions as scientific evidence.

First, the title of the report is truly Orwellian, Evidence Based Maternity Care: What Is It and What Can It Achieve. The title is Orwellian because virtually none of the conclusions are supported by evidence in the paper or any evidence at all. The fundamental claim, that “natural” childbirth with minimal intervention is better, safer and healthier is not supported by scientific evidence. This is a classic example of using “scientese” to trick people. Obstetrics is evidence based medicine. Natural childbirth is values based opinion. Trying to hide that fact does not fool anyone who is familiar with the actual scientific evidence.

Second, the willingness to place personal opinion above scientific evidence is best exemplified by the section of the report on epidurals.

… Labor epidurals alter the physiology of labor and increase risk for numerous adverse effects. Undesirable maternal effects include immobility, voiding difficulty, sedation, fever, hypotension, itching, longer length of the pushing phase of labor, and serious perineal tears.

The authors provide no references to back up these claims. The central claim, that epidurals alter the physiology of labor is flat out false. The scientific evidence shows the opposite.

The authors have simply fabricated several of the so called “undesirable” maternal effects including immobility, and sedation. That begs the larger question: undesirable to whom? The answer is that the side effects (the real ones, not the made up ones) are undesirable to the members of Childbirth Connection. The authors provide no evidence that the patients consider these side effects to outweigh the benefits of effective relief.

Indeed, the authors acknowledge that the majority of women do not share their disdain for epidurals, but in the classic manner of “natural” childbirth advocates, they ascribed it to ignorance without offering any proof.

Many laboring women welcome the pain relief of epidural anesthesia, but they do not appear to be well-informed about the side effects.

Once again the authors present no evidence for their implication that women would forgo pain relief if they were “better” informed.

Third, the report, like virtually all natural childbirth and homebirth advocacy is filled with deliberate distortions. The authors compare neonatal mortality rates among countries, and fail to compare the more accurate measurement of perinatal mortality. The authors discuss the “charges” for obstetric procedures instead of the actual reimbursements. The authors claim that systematic reviews “give the most trustworthy knowledge about beneficial and harmful effects of specific health interventions,” but that is flat out false. Systematic reviews are completely dependent on the quality of the studies that the authors choose to include and whether those studies are representative of the existing scientific literature. Systematic reviews are a good starting point for evaluating obstetric procedures, but they are hardly the “most trustworthy” sources of scientific information.

This report from the Childbirth Connection is not consistent with the scientific evidence, and is not consistent with the desires and values of the majority of American women. It is more aptly titled Ignoring Mothers: Our Advocacy Efforts Aren’t Working.

Adapted from a piece that first appeared in October 2008.

As the website First World Problems explains, “It isn’t easy being a privileged citizen of a developed nation.”

Consider:

The sun is too bright for me to read my iPhone screen.

Or:

I tried to unlock the wrong Prius today. Twice.

And my personal favorite:

I can’t find the remote.

Evidently it isn’t easy being a childbirth organization in first world country with extraordinarily low rate of perinatal and neonatal death. Hence the creation of first world problems that are the raison-d’être of childbirth organization.

As Madeline Akrich and colleagues explain in Practising childbirth activism: a politics of evidence:

What do childbirth organisations in Western countries do? A review of existing literature reveals a degree of similarity in their causes which cluster around four key goals: (1) problematising medical/technical intervention in birth; (2) promoting “natural”/”normal” or “mother friendly” birth; (3) demanding birth practices and settings that are attentive to and respectful of the desires of birthing women and their families and (4) championing women’s right to make informed choices about type and place of birth.

All four “causes” epitomize first world problems. By that I mean that these “problems” make no sense anyplace except where it is taken for granted that childbirth is incredibly safe and that access to emergency childbirth care is easily accessible, and always available.

In other words, contemporary childbirth organizations like Lamaze, the Childbirth Connection, etc. work tirelessly to convince women that first world problems are real, devastating and demand immediate action. It’s a tough job, as evidenced by the first goal, which involves convincing women who are otherwise satisfied that there is a problem in the first place.

The authors describe that goal very well: problematizing birth interventions. It is absolutely critical for childbirth organizations to convince women that the interventions that save the lives of countless babies and mothers are “bad.” They employ a variety of strategies to accomplish this critical goal. These organizations thrive by creating dissatisfaction and can’t exist without it.

The strategies include claiming that childbirth interventions are:

• unnecessary
• unsafe
• overused
• harmful to the mother child-bond.

It doesn’t matter whether the claims are true or not; most of them are false. Facts and scientific evidence have nothing to do with “problematizing” birth interventions.

It is this overwhelming need to “problematize” that explains some of the otherwise inexplicable tactics of childbirth organizations. The constant references to perineal shaving and enemas more than 30 years after they were dropped from practice is explained by the fact that existing childbirth practice are necessary. The demonization of C-sections is critical to convincing women that childbirth interventions are both unsafe and overused. Finally, the utterly fabricated claims about childbirth pain, interventions and bonding are used to convince women to fear and avoid the very interventions that can save their babies’ lives.

All these strategies are deployed in an effort to create the ultimate first world problem: “My birth experience was ruined.” All childbirth organizations, and many midwifery organizations, depend to a greater or less extent on convincing women that they have this first world problem and childbirth organizations have the solution: promoting “normal” birth.

“[N]ormalisation [of birth] is…the current driving force”… [T]he desirability of “normal” birth and guidelines to promote its achievement are widely espoused and integrated into international and national guidelines for the governance of health (WHO, 1996; NICE, 2007), into the professional self-definition of many midwifery groups at international and national levels and into the objectives of a range of lay childbirth organisations.

Both women and birth are reduced to their purported “essences,” with the assumptions that technology destroys the essence of birth, and that the essence of all women is to desire a birth without technology. There is no room for individual beliefs and choices and indeed, these are denigrated as false consciousness resulting from societally induced “fear” of birth.

The third goal of childbirth organizations, ostensibly to demand processes that are more respectful of women, is a bit misleading. The real goal is to demand processes that are more respectful of natural childbirth professionals (like midwives, doulas, and those who run childbirth organizations). That’s the whole point of “problematizing” technology in the first place. Practically speaking, “technology” is anything that cannot be provided by midwives, doulas and childbirth organizations.

The fourth goal, championing women’s choices, is also misleading. Only specific choices (those that can be provided by midwives, doulas and childbirth organizations) are championed. For example, I’m not aware of a single childbirth organization that champions a woman’s choice for an elective C-section or even for the general concept of applying more technology to childbirth.

The bottom line is that childbirth organizations exist to promote themselves. To that end they work tirelessly to create first world problems around childbirth and to convince women that they are the answer to the very first world problems that they have created.

The goal is to convince women they are suffering from the ultimate first world problem:

I had childbirth interventions and all I got was a healthy baby.