I have received word of an incredible tragedy. A Florida mother of 6 died in the wake of an attempted homebirth.

I have tried to assemble as many details as possible, but several reports on birth related websites were removed over the past day.

The mother posted on homebirth websites and reported that she had already had one successful homebirth after 2 previous C-sections.

In the wake of her death, a friend began soliciting breast milk for her baby:

A beautiful, wonderful, amazing friend of mine passed away on Monday (08/22/11) after giving birth to her sixth child just a day before. She never got to meet her son, as she had lost so much blood by the time he was taken via emergency cesarean section. She tried so hard for this last pregnancy, and continued to nurse her second youngest (nearly 2 now) through it. She was a beautiful, WONDERFUL soul…

Her doula Michelle Fonte had posted a prayer request on August 21:

PLEASE. energy. thoughts. prayers for a very special mama of mine. in the hospital. who needs all of our help. she needs you. really. really.

and an update on August 22:

mama is strong and stable…but has a long way to go. please continue to keep her in your thoughts and prayers. thank you so so so much.

Unfortunately, she died later that day.

In the wake of her death, her former physician who runs a “holistic” practice posted:

I would also like to extend prayers to my former patient who did not make it. We were due at the same time … a beautiful woman/spirit. So sad how we have to expose ourselves to such risk since we can not rely on the “establishment”.

Sad? Sad is not the word I would have used to describe the decision to take such a terrible risk.

Dr. Isis has certainly struck a chord. Her post Your Home Birth is Not a Feminist Statement is being widely discussed on the web.

Here’s the “money quote”:

Home birth as a way to find a loving supportive environment and fight the enslavement of the patriarchy is absolute, utter nonsense. It’s one of the only medical scenarios I can think of where women place health and welfare in jeopardy in order to feel “in control” and avoid intervention.

She examines the data on the safety of homebirth and states:

If you can look at those data and still decide … to choose home birth, then I say “You go get ’em, Gloria Steinem!” But, you should know that I’m going to judge you. Choosing to deliver at home because it makes you feel empowerful isn’t a feminist act. It’s a selfish one…

She draws the obvious parallel with vaccine rejectionism:

It’s no different from the attitudes of the anti-vaccine mothers who choose delayed vaccination schedules, or no vaccines at all, because it makes them feel safe and in control of their children’s well-being. You might feel empowered, but the data tell us that you are hurting your children with your choices…

She concludes:

I can think of no other women’s health area – Pap screening, breast cancer treatment, HPV vaccination, in which forgoing a treatment shown to improve health outcomes would be flown on a feminist banner…

If feminists care about empowering women during child birth, they should do so in an evidence-based manner… We should be continuing to ask how can we make women feel empowered in an environment that offers the best chance of survival for their offspring. This home birth talk is shenanigans.

Dr. Isis was quoted approvingly here: Home Birther Logic. or “Logic” actually, but Kate Clancy, an anthropology professor, takes issue:

I empathize strongly with those who advocate home birth, and I am not completely against it. And I think that comes from a number of places… But when I see this population of women denigrated, called “homebirthers,” essentialized, and conflated with anti-vaxxers, I feel like something needs to be said.

What should follow is an exposition demonstrating that homebirth advocates do not believe in biological essentialism or are not more likely to be vaccine rejectionist, but Clancy offers no evidence to rebut Dr. Isis. That’s because there is no evidence. Biological essentialism is a critical component of homebirth belief starting from Grantly Dick-Read (the “father of natural childbirth”) right through Ina May Gaskin who is a staunch biological essentialist.

Moreover, it is well known that homebirth is closely associated with vaccine rejectionism. A CDC presentation, The Association between Birth Place, Birth Attendant, and Early Childhood Immunizations, offers compelling data:

Overall 132,473 Oregon births were included in this study… The 2,200 children who were born in locations other than a hospital or freestanding birthing center were 8.8 times more likely not to be seeking or receiving immunizations than those born in hospitals. Those with a direct-entry or non-certified midwife in attendance were 7.4 and 8.8 times more likely to not be shot seeking as those with an M.D…

When I presented this information in the comments, Clancy blew it off with this non-sequitur:

Amy, please read two of the comments above yours, both by scientists who have had home births, and link to their own birth stories and their own justifications for their home births, before you paint all women who advocate home birth with the same brush.

Then Clancy demonstrates a complete failure in her understanding of mortality statistics. She appears to believe that perinatal mortality (deaths from 28 weeks of gestation to 28 days of life) means deaths of premature babies starting at 28 weeks of gestation:

… It would be stupid to try and give birth to a baby at home before 38 weeks; it would be taking an unnecessary risk. This is why I take issue with Dr. Tuteur trying to change the metrics for evaluating infant mortality to include those births that it would never, ever make sense to have at home or in a birth center…

All and all, I’d say that Kate Clancy offers an excellent example of what I always warn against, women who think they are “educated” about obstetrics but have no idea what the scientific evidence shows and no idea what the scientific terms even mean*, and what Dr. Isis was highlighting, “women [who] place health and welfare in jeopardy in order to feel “in control” and avoid intervention.”

*rather startling that she claims to be studying the anthropology of women’s reproductive physiology but doesn’t know the definition of the terms used to measure women’s reproductive outcomes.

Homebirth advocacy has become so extreme that it is occasionally difficult to tell the difference between a real story and a hoax. This story posted on Mothering.com sounds so extreme as to be a hoax, but readers can decide for themselves.

On 7/20, klamp posted on Mothering.com:

… I had mentioned no prenatal care/self prenatal care and the intention of a UC. Due to this post everyone is flaming my thread, saying that I am neglectful, ignorant, uneducated; there are even posts saying “screw you”… Why should I be bound to diabetes testing, blood testing, urine testing, pressuring, poking and prodding if I do not want to be? Better yet why is society so reliant on medical professionals and to the extent that it is viewed as required? I feel like I am missing what the big deal is.

Here’s the birth story, posted on 8/21. It starts of promisingly:

For all of you out there considering or determined to have a UC, congratulations. It is empowering, exhilarating and I am a firm believer of having healthier babies and easier births due to UC.

I was one who didn’t receive any prenatal care or use a midwife; I found it pretty useless as I could weight myself, check my blood pressure I felt sense able enough to know if something felt wrong. I tracked his positioning and even knew that he was a boy!

I went into labor at 1 a.m. on July 18th of this year and had Tyson at 9:08 a.m. My partner was there and was supportive …

So everything turned out great, right? Not exactly.

Rubbing the outside of my vagina, I felt a large bulb and told my partner that the head was coming out, he was just about here! There was a loud bang and my amniotic sac literally exploded and the water covered the bathroom. His foot immediately came after wards. We were shocked, sure he was head first. I didn’t panic right away, I knew that breech, vaginal births were totally possible.

But they handled it successfully, right? Not exactly.

The next foot came seconds later and he came out up to an inch above his belly button. This is where I panicked he wasn’t coming any further and was stuck, I had my partner call the ambulance. Throughout the course of the call I was told to try different positions with my boyfriend pulling, pushing, prying and the baby had turned a deep shade of purple and was no longer moving when I tickled his foot. We were certain that he was dead by the time the ambulance had gotten there.

What ensued was a virtual horror show. The EMTs were unable to deliver the baby and elected to transport the mother to the hospital.

… They carried me down the stairs sin my comforter, while I held my baby up, still stuck. The man in the ambulance was trying to get his arms down, which was keeping him from coming him out, Tyson had his arms raised up so his shoulders were in the way. They had my push but I was exhausted and … I had given up, I didn’t see the use in it because I knew in my heart he was dead anyways. I give a huge push and feel terrible finally the EMT in the ambulance got his arms down and there was a huge release of pressure and I could feel Tyson Sliding out… [I]t was nice feeling his skin against mine but I could see he was still a very dark purple.

The baby was not dead. The EMTs and hospital personnel manage to resuscitate him and keep him alive.

klamp reports:

There is no feeling like the feeling of having a baby dangle halfway out of your vagina while you are certain that it is dead. There is no way to explain the guilt, terror, depression, anger and other emotions that we have gone through. Tyson might have brain damage but after being stuck for over 10 minutes and all the progress he has made as well as the brain’s ability to regenerate and reroute it looks promising that he will lead a healthy and normal life.

klamp suggests that maybe getting prenatal care isn’t such a bad idea after all:

… Don’t just guess or go on instinct, make sure, this has been so painful and I don’t want it to happen to others. I would still have a home birth it was an amazing experience up until the foot came out and I encourage others not to be afraid but to be safe and protect themselves and their babies. Good luck!

Jill Arnold at The Unnecesarean wrote an interesting recap of a discussion that occurred on her blog between Ina May Gaskin and me. What’s most interesting about it is Jill’s conclusions.

Jill quotes two comments.

Ina May:

… I understand now that one reason that Dr. Tuteur has objected so strenuously to my ideas comes from the helplessness she and other staff members felt during her residency when those three mothers who did need obstetrical intervention refused it, unaware that their babies really could (and did) die for lack of it…

I didn’t make up the incident … in which repeating the traditional wedding vows made it possible for my friend’s cervix to dilate fully after she had been stuck at 7 cm for more than a day. She gave birth about an hour and a half after that impromptu ceremony. I realize, of course, how hard it can be for anyone who prides herself on being “rational” and skeptical to accept this, but I’m stuck with what did happen. There were witnesses…

I don’t find it at all hard to believe that he encountered tribal people whose experience told them that a labor could be prolonged when a mother had a sexual secret that she was keeping. It doesn’t mean that will happen with everyone, but it does happen sometimes. And no randomized controlled trial will ever demonstrate this…

And my response:

You don’t have to conjure up any secret motivations. I’ve explained why I object strenuously to your ideas: I find your philosophy of biological essentialism and anti-rationalism completely unpersuasive, and I have pointed out ad nauseum that most of your empirical claims are factually false. That’s more than enough reason to explain why I disagree with you.

In recounting those anecdotes, I was not describing my “helplessness” since I did not feel helpless. I recounted those anecdotes specifically to illustrate my claim that homebirth and NCB advocates don’t understand the risks of their choices because the NCB literature is silent or lies about those risks.

Let me make myself very clear, Ms. Gaskin, so you cannot twist or misinterpret what I mean. I disagree with almost everything you say because I think you are wrong. The scientific evidence does not support your claims, and your invocations of non-rational forces and energies is nothing more than quackery. (my emphasis)

Jill’s take on the discussion:

Amy has more or less placed the OB philosophy in the science category and NCB philosophy in the mysticism (or non-rational) category. Scientism holds science as superior and therefore will always trump any non-empirical philosophical explanations for phenomena…

I agree wholeheartedly that NCB philosophy, at its purest and as I understand it, is biological essentialism. It ranks unmedicated, vaginal birth as superior to all other ways to become a mother.

Unfortunately, Jill goes on to confuse the impact of the mind on the body (“psychosomatic aspects”) with anti-rationalism:

The source of contention seems to be whether or not there is a psychosomatic aspect to pregnancy and labor … This is the classic debate between the Cartesian view of the patient (edit: the patient’s body) and what psychosomatic medicine refers to as the “body-mind.” It bleeds through into discussions about alternative medicine … And if there’s anything on science blog …that will drive scientists and doctors up the wall, it’s claiming that a treatment works based solely on a personal experience.

But the impact of the mind on the body is a concept firmly embedded in science. Non-rationalism is the idea that there are OTHER forces, like spiritual forces, that come from outside the body to impact the body. It also invokes the idea of special powers such as intuition that give certain people secret knowledge.

Jill concludes:

Within the framework that Amy is working, I’d have to say (as a layperson, so who cares, right?) that most non-biological (i.e. psychological) claims about birth are unscientific, as they are yet unproven. Neuroscience appears like it might someday bridge that gap, but as of yet, it hasn’t.

She goes on to say

As far as correctness and being right is concerned, a cultural relativist (like me) will hold that separate philosophies are equal and can both lay moral claim to rightness, with none being superior to the other.

And that is the quintessential anti-rationalist claim. All ways of looking at things are equal. Empiricism and rationality shouldn’t be privileged. Women have other ways of knowing.

As I understand it, Jill is saying that it is her personal belief that vaginal birth is best even though that’s not what the scientific evidence shows. She has every right to that personal opinion as do other NCB and homebirth advocates, but they need to realize what Jill has acknowledged: the scientific evidence does NOT support the claims of NCB or homebirth advocates.

I first wrote about Dr. Stuart Fischbein two years ago (Can you still be “Dr. Wonderful” after conviction for sexual exploitation of a patient?):

You might think that such a doctor would be a pariah among patients, especially after a conviction, and the decision by the California Board of Medicine to place him on probation for 7 years, but you’d be wrong about this doctor. He is currently soliciting donations from patients and supporters for his latest legal woes … and women are proudly giving money.

Recently, Dr. Fischbein petitioned the California Board of Medicine for early termination of his 7 year probation. You can read the 6 page opinion denying his request here. The board was unimpressed with Dr. Fischbein’s request for a variety of reasons detailed in the report. However, most compelling to them was the fact that Dr. Fischbein has attempted to make a movie promoting “his side” of events, and portraying himself as a victim.

12. In the Fall of 2007, after Petitioner was placed on probation by the Board, he began working with a screenwriter friend on a … a script entitled “Bedside Man.” By this time. Petitioner had already completed the PACE Professional Boundaries program. The cover of the script states it is “based on a true story,” and credits “Story by Stuart Fischbein.” A promotional trailer was later made, in which Petitioner was also involved and credited… Although fictional names are used in the story, the script and trailer are obviously based on Petitioner’s version of events. [They] tend to minimize Petitioner’s culpability, make him look more like a victim and his victim less of one, and depict Petitioner as being persecuted for his views on some aspects of medicine.

13. In an effort to promote “Bedside Man” for financial investment to make a full length movie, the trailer was made accessible over the internet. One hospital where Petitioner was affiliated found out about it and contacted Petitioner’s psychotherapist… From her letter detailing the events, it appears that [she] was readily able to see the impropriety of the project while Petitioner had not. She told him that the project “did not represent him as a man who had made a terrible error in judgment.” [The psychotherapist] persuaded Petitioner that the project was an error and for the trailer to be removed from the internet. Petitioner has done so.

The Board did not terminate the probation, writing:

[He] views probation as punishment and an inconvenience… Although he no doubt has encountered difficulties practicing while on probation, he still tends to overstate those difficulties. He has openly chaffed at the requirement that he have a third party chaperone during interactions with female patients. It is clear that once off probation, the chaperone requirement would quickly disappear from his practice as the lessons learned from these events fade and the inconvenience grows…

The report concludes:

More alarming was Petitioner’s participation in the movie script and trailer. This activity shows that Petitioner still harbors bad feelings about what happened to him, suggesting that he does not fully believe he engaged in misconduct… Such a state of mind does not bode well for the proposition of removing Petitioner completely from the Board’s probationary oversight. In all, these events demonstrate sufficient concern over the course of Petitioner’s rehabilitation as to indicate that continuing probation with all terms should continue in order to protect the public…

I don’t hesitate to call out natural childbirth bloggers when they disseminate misinformation, so it is only fair that I compliment them when they go out on a limb to make brave pronouncements.

Check out the latest post by Mama Birth, Why the Natural Childbirth Community Must Not Ignore Her Critics. It does, of course, start with the expected denigration:

Not often, but occasionally I take a peek at one of those awful anti- natural childbirth websites. You know the ones I am talking about. They mock natural birth, non-vaccinating parents, Chiropractic, herbal remedies and all those who follow those types of lifestyle choices. They have a special place in their hearts for the unassisted birther or the woman who claims that childbirth was painless and wonderful. They particularly disdain midwifery, particularly the home birth variety…

But then comes the unexpected:

… [S]ometimes I find something that is kind of disturbing on their blogs. You are not going to appreciate me saying this, but sometimes they say things that are…..

True.

Mama Birth explains that there are two main claims that we make that ought to be heeded:

1. Homebirth midwives can behave in ways that are dangerous to babies and mothers

There are bad midwives… I mean midwives who trust birth and say all the right things and even think all the right things- but who are simply incompetent, dangerous, or unethical.

I have heard awful stories of midwives who can’t start an IV when it is needed, who don’t carry drugs for stopping hemorrhage, who can’t properly suture and even who are unable to provide infant CPR… I have talked to midwives who … inflate their abilities in order to get clients.

We must open our eyes to some of the problems within midwifery that make it possible for incompetent and even dangerous midwives to continue to practice. This can only be ignored at our peril. We must carefully choose our own midwives. If we are studying or training to be a midwife, we must do more than just trust birth. We must be able to recognize when it can’t be trusted. (my emphasis)

2. Many claims of homebirth and NCB advocates are not supported by the scientific evidence.

… [S]ometimes I notice that some of the things stated, claimed, or quoted among natural types are not true, not substantiated, not based on evidence, or are misinterpreted.

For the natural birth community to be respected we must speak the truth. We must also back up what we say with some real evidence. It is out there, but just because it is on somebodies blog, doesn’t mean it is true. (my emphasis)

I admire Mama Birth for having the courage to speak truth to power. The celebrities within the community and their acolytes wield power in that community and they do not hesitate to use it harshly to suppress dissent and to marginalize any midwife or homebirth advocate who does not follow the party line. It takes bravery to speak up for babies and mothers and risk condemnation by one’s peers.

What might have precipitated Mama Birth’s post? Only she can tell us, but I wonder if the publicity given to the recent homebirth deaths has been a factor. Many babies have died in the past few months, generally when midwives were violating the law, and usually because the midwives themselves were unsafe practitioners. Instead of investigating, though, the NCB and homebirth communities closed ranks behind the midwives without even bothering to determine if they were at fault, and without offering any support to the bereft parents.

I also wonder if this is one of the first glimmers of dawning realization in the NCB and homebirth communities. What might they be realizing? Finally, NCB and homebirth advocates may be recognizing that the public positions they have taken don’t benefit mothers and babies. They benefit homebirth midwives AT THE EXPENSE of mothers and babies.

The reality is that no law can take away a mother’s right to give birth at home, and no law can take away her right to be attended by whomever she chooses. Laws that regulate homebirth midwifery don’t impact these rights, and therefore, they don’t threaten the choices of mothers who wish to have a homebirth. However, they do impact the ability of homebirth midwives to get PAID for attending birth.

Even a cursory inspection of current and proposed laws about homebirth midwives reveals that every single legal effort is designed to increase the chance that a homebirth midwife will get paid, and to decrease the education and skills that she must have in order to qualify for payment.

A very simple example is the sad case of Margarita Sheikh and her baby Shazhad. Midwives in Oregon oppose mandatory licensure. But if mandatory licensure had been in place, it wouldn’t have prevented Margarita from having a homebirth and it wouldn’t have prevented Darby Partner and Laura Tanner, two unlicensed midwives, from attending her. What it would have prevented is Darby Partner and Laura Tanner CHARGING MONEY for attending Margarita’s birth. And it certainly would have prevented Darby Partner and Laura Tanner from getting away scot-free after presiding over Shahzad’s completely preventable homebirth death.

No doubt Mama Birth is going to take a lot of criticism for speaking out on behalf of mothers and babies. It’s only fair that she also gets some praise for bravely doing so.

You can’t make this stuff up. (For those who might be wondering, this is NOT a satire.)

A mother, writing yesterday on an Australian parenting website, had this to say:

I’m 32 weeks pregnant and just found out yesterday that the hospital I wanted to birth at, thought that I WAS birthing at has rejected me “because I don’t fit their birthing criteria”.

This is a BIG deal for me. This is my fourth bub but my first hospital birthing experience. It has taken a long time for me to be “OK” with the idea that this baby won’t be born at home, like my other 3 children…

Why is this mother considered high risk?

After an amazingly simple and straight-forward and glorious first birth, my second daughter “got stuck” (our belief as to why this happened differs from “the experts”… so, apparently, we have no clue and are wrong!! We believe it was the distracted (sic) labour, they believe it was my daughter’s size) and needed some resusitation (sic) when she was born.

That’s not the only problem:

After a very “political” and battle-weary third pregnancy (trying to achieve the kind of birth I knew I needed), something (nobody knows exactly what) went wrong right at the end of the labour and our little boy was born unresponsive and died 2 days later in hospital.

But the birth of the dead baby did have a bright side:

NB. Bub was BIGGER than his sister and DIDN’T get stuck!

Phew! At least she got the birth that SHE needed, even though the baby didn’t get the oxygen he needed.

Just because one of her babies died and the other nearly died at homebirths, the mother can’t understand why doctors are concerned:

Now I know there will be those of you out there going “well, I’d say they have good cause to be concerned by your birthing history”. My point is, WE aren’t!! We don’t look at what has happened and automatically go “oh no! That is going to happen again! Oh no! Oh no! Oh no!”

… If WE aren’t “frightened…. why do THEY need to be?? Why can’t we all assume everything is going to go fine and IF something does go pear-shaped, let’s deal with it then. WHY DOES THERE HAVE TO BE SO MUCH FEAR AROUND CHILDBIRTH??

Why can’t we all assume everything is going to go fine and if something does go wrong, we can deal with it then?

Let’s see. I’m wracking my brain and scratching my head at this question.

Not because I don’t know the answer. The answer is painfully, glaringly obvious:

YOU DID THAT THE LAST TWO TIMES AND IT DIDN’T WORK OUT TOO WELL, DID IT?

I’m wracking my brain and scratching my head at the question because it is difficult for me to fathom that after burying a baby, a woman could still be more concerned about HER birth experience than preventing the death of her next baby.

Why does there have to be so much fear around childbirth? If this mother can’t understand, I can’t possibly explain it to her. But I do have one question for her:

How stupid and self absorbed do you have to be to ask these questions after your baby died?

Oh, dear. Homebirth and midwifery advocates appeared to be having great success with their campaign to discredit obstetrics as “not based on scientific evidence.” But then it turned out that obstetrics IS evidence based.

Time for a change in tactics: Obstetrics shouldn’t be based on something as cold and impersonal as … scientific evidence!

I’ve written many times about popular smear strategy of accusing modern obstetrics of ignoring scientific evidence. The celebrity natural childbirth advocate Henci Goer has stake her entire professional life on the smear. As recently as this week, a major homebirth organization distributed a (hypocritical and mendacious) press release accusing obstetricians of having evidence that was less than perfect to support some of their recommendations (no other kind being available currently).

That’s why I laughed out loud when I read the latest opinion piece by Dr. Mark Keirse in the journal Birth, The Freezing Aftermath of a Hot Randomized Controlled Trial.

Dr. Kierse is publicly known for his relentless support of breech vaginal delivery. Now he dolefully acknowledges that the existing scientific evidence, of the highest quality, shows that C-sections are safer. And Dr. Kierse makes it clear that breech homebirth is NOT a safe alternative:

Home birth is a well-established recipe for disaster for a baby in breech presentation and contrary to any sensible guidelines that have ever been developed. (my emphasis)

Given that the scientific evidence supports C-section for breech, patients face two choices, C-section or unsafe homebirth. Dr. Kierse is eager to place “blame” for this outcome.

Clearly, the blame must rest fairly and squarely with what was heralded as a new paradigm, “evidence based medicine” … [which] means a new scientific order in which there is no place anymore for the concepts of old. In the new evidence-based paradigm anything randomized became the gospel and anything else became either low evidence or lack of evidence. (my emphasis)

In fact:

Obstetrics, perhaps even more than any other discipline, fell victim to this new paradigm determined as it was to get rid of the slur that had hounded the specialty before.

And just who was responsible for the slur? Why none other than midwifery and homebirth advocates. Oh, the irony!

Dr. Kierse acknowledges that the recommendation of C-section for breech is based on rigorously, obtained high quality scientific evidence.

A fundamental issue is that probably no study with selection and management criteria such as those applied in the term breech trial would have seen the light of day in a prestigious journal if it had not been randomized.

Kierse then peevishly dismisses the value of rigorously obtained, high quality scientific evidence:

Of course, nothing is wrong with advocating or promoting randomized trials. There is a great deal wrong, though, with the perception that evidence, to be evidence, needs to be randomized evidence. There is also a great deal wrong with the belief that only evidence is an e-word that deserves to be written with a capital “E,” whereas other e-words, such as education, experience, expertise, and even excellence, are merely ignominious. (my emphasis)

So after years of insisting that the recommendation for breech delivery by C-section was not based on scientific evidence, Kierse now claims that, oops, scientific evidence isn’t really that important anyway.

Just in case you didn’t pick up on the claim that scientific evidence isn’t really that important after all, Dr. Kierse hammers it home with his clunky title. Those mean, heartless obstetricians are making recommendations based on cold scientific evidence and thereby “freezing” out warm, loving recommendations for a vaginal birth that could kill your baby.

Time to edit the midwifery and homebirth battle cry:

Don’t listen to obstetricians, because their recommendations aren’t are based on ^^{cold, impersonal} scientific evidence!

Imagine this scenario: A woman, after reviewing the evidence from both sides, after carefully considering the increased risks, and after deciding that she is willing to accept the responsibility for the outcome, decides to … smoke cigarettes.

This situation happens all the time. Indeed, a substantial portion of the population smokes cigarettes. In 2011, everyone knows that cigarette smoking increases the risk of lung cancer, emphysema and other diseases. However, most smokers will accurately point out that not everyone who smokes gets a smoking related illness, that smoking provides both pleasure and concrete benefits such as relaxation and increased concentration, and that adults are entitled to make their own healthcare choices. In addition, there are scientists who assert, and who have testified under oath, that the harms from smoking have been dramatically exaggerated.

So if a woman claims to have made a knowledgeable decision to smoke cigarettes, and is aware of the potential consequences, does that mean that she is “taking responsibility” for her health?

In one very real sense, it does, since she is the one who will suffer if any harmful effects ultimately occur. She is the one who will gasp for breath with emphysema, she is the one who will endure treatment for cancer and who may die a painful death from it. However, it most other ways, she has no intention of “taking responsibility” for her health.

First, most women who elect to smoke cigarettes have some measure of denial about what is can happen. They tend to grossly underestimate the risks of getting a serious illness; they tend to be unaware of a variety of less common illnesses caused by smoking (bladder cancer, peripheral vascular disease); and they tend to drmatically underestimate the impact that emphysema, lung cancer and other diseases will have on their life as a whole. So while they may be technically “educated” about the risks, they are not acting with a clear eyed assessment of those risks.

Second, smokers have no intention of managing any complications alone. If they get emphysema or cancer, they will expect and demand state of the art treatment for those diseases. They caused their own disease, but they will expect and demand that others do everything possible to cure or at least ameliorate it. Moreover, they have absolutely no intention of paying for their decision. They bought insurance for just this eventuality. As far as they are concerned, other, healthier people can pay for their illness with higher premiums overall.

In a very real sense, they don’t plan on taking ANY responsibility for their health. They plan on other people doing all the work, and paying most of the money to rescue them if their choices were wrong. The bottom line is that women who “take responsibility” for smoking are generally in denial, grossly underestimate the risks of serious harm, have no intention of fixing their own medical problems, and have no intention of paying the bulk of the cost from those problems.

Homebirth is very similar. Most homebirth advocates have no clue as to the real risks of homebirth. Second, most homebirth advocates are in denial about the fact that serious complications can occur in low risk women. Third, homebirth advocates expect, demand (and sue) for state of the art medical care to rescue their babies and themselves from their own choices. Fourth, homebirth advocates have absolutely no intention to pay the bulk of the costs that may result for their poor choices, ranging from a long term stay in the NICU to life long special needs assistance for an impaired child.

In other words, all the talk about homebirth advocates “taking responsibility” for birth is just talk. In the ways that count, homebirth advocates expect everyone else to do all the work, take all the responsibility and shoulder the bulk of the expense for their choices. Homebirth advocates intend to take precisely the same responsibility for their health that smokers intend to take, in other words, no responsibility at all.

A version of this piece appeared on Homebirth Debate in March 2008.

One thing you have to say for homebirth midwives. They have chutzpah. They are grossly undereducated, grossly undertrained, and ineligible for licensure in any first world country, but when it comes to hypocrisy and mendacity, they are second to none.

Consider the following press release sent out to news outlets by The Big Push for Midwives, a national campaign to license homebirth midwives so they can collect insurance reimbursement.

Here’s the first paragraph:

A study published this month in Obstetrics & Gynecology, the journal of the American College of Obstetricians and Gynecologists, found that barely one-third of the organization’s clinical guidelines for OB/GYN practice meet the Level A standard of “good and consistent scientific evidence.” The authors of the study found instead that the majority of ACOG recommendations for patient care rank at Levels B and C, based on research that relies on “limited or inconsistent evidence” and on “expert opinion,” both of which are known to be inadequate predictors of safety or efficacy.

That sounds bad (and it is meant to) until you understand that the rating system for clinical guidelines: A (good and consistent evidence), B (limited or inconsistent evidence), or C (consensus and opinion). In other words, there IS scientific evidence for ACOG recommendations, but not all of it is of the same quality.

What’s hypocritical and mendacious about the press release from The Big Push for Midwives?

When it comes to the practices exclusive to homebirth midwifery, 0% meet Level A guidelines!

… and 0% meetLevel B guidelines; and even 0% meet the lowest level, Level C guidelines. That’s because there is NO evidence of any kind to support the practices exclusive to homebirth midwifery.

Homebirth in the US- no evidence of efficacy or safety

Refusing postdates induction- no evidence of efficacy or safety

The Brewer diet- no evidence of efficacy or safety

Home VBAC- no evidence of efficacy or safety

Herbs – no evidence of efficacy or safety

Chiropractic in pregnancy – no evidence of efficacy or safety

I could go on and on, but you get the idea. It is both hypocritical and mendacious to send out a press release accusing ACOG of having less than perfect evidence when homebirth midwifery has no evidence at all.

The ultimate irony? The Level of Evidence for the actual paper that The Big Push is quoting, Level III, is the lowest possible level!