How safe could homebirth and waterbirth be when pediatricians, those who know the most about the health and safety of babies, are opposed?

It is an article faith among homebirth advocates that homebirth is as safe or safer than hospital birth. It is an article of faith among many of them that waterbirth is a safe and gentle method of entering the world. It is an article of faith among natural childbirth advocates that NCB is better for babies. It’s all rather astounding when you consider that pediatricians have gone on record that birth in a hospital or an associated birth center is the SAFEST place of birth.

The Guidelines for Perinatal Care published by the American Academy of Pediatrics (AAP) and American Congress of Obstericians and Gynecologists (ACOG) state that:

the hospital, including a birthing center within the hospital complex, or a freestanding birthing center, provides the safest setting for labor, delivery, and the postpartum period. The use of other settings is not encouraged. Further, any facility providing obstetrical care should have the services listed as essential components for a level I hospital. This includes the availability of blood and fresh-frozen plasma for transfusion; anesthesia, radiology, ultrasound, electronic fetal heart rate monitoring and laboratory services available on a 24-hour basis; resuscitation and stabilization of all inborn neonates; nursery; and other services that are not available in the home setting.

It’s difficult to be clearer than that. There is no hedging or equivocation. Pediatricians insist that hospital is the SAFEST SETTING and that homebirths should be discouraged. Why? Because safety demands electronic fetal heart rate monitoring, personnel and equipment for neonatal resuscitation and a nursery staffed by nurses who can monitor even well babies.

The AAP is, if it is possible, even more strongly oppoesed to water birth. The American Academy of Pediatrics Committee on the Fetus and Newborn released a comprehensive report in 2005 that waterbirth is not safe for babies. The report, Underwater Births, states:

The safety and efficacy of underwater birth for the newborn has not been established. There is no convincing evidence of benefit to the neonate but some concern for serious harm. Therefore, underwater birth should be considered an experimental procedure that should not be performed except within the context of an appropriately designed RCT [randomized controlled trial] after informed parental consent.

So pediatricians are OPPOSED to homebirth and especially to waterbirth on the grounds that they are unsafe. What about natural childbirth?

With the exception of fringe professionals like the Drs. Sears, pediatricians find no particular benefit to natural childbirth. It’s not safer, healthier or better in any way for babies. That’s because there is no evidence that pain relief in labor is harmful to babies, no evidence that electronic fetal monitoring is harmful to babies, and no evidence that vaginal delivery is safer for babies. In fact, the bulk of the existing evidence suggests that C-section is unequivocally the safest method of birth for babies.

It’s a trifecta! Pediatricians oppose homebirth, they oppose waterbirth, and they can find no benefit to natural childbirth.

But, hey, who are you going to believe when it comes to the safety and well being of babies? Pediatricians, whose sole concern is the safety and wellbeing of children, or Ricki Lake, Henci Goer, Jennifer Block and Barbara Harper, women who lack basic educations (or, in some cases, ANY education) in science, statistics or pediatrics whose sole concern selling DVDs, books, courses and anything else that will generate a profit?

It’s difficult to be more definitive than that: there is no evidence of benefits and the possibility of serious harm.

Dear God in Heaven, when are these people going to wake up to what is right in front of them? Homebirth kills babies who didn’t have to die.

The latest needless, senseless, utterly predictable and totally preventable homebirth death is currently being discussed on the Birth Without Fear Facebook Page, which links to the original story and a picture of a beautiful baby who looks to be sleeping but who is actually dead.

I had the most simplest pregnancy, and the healthiest baby boy, decided at 8 months to ditch my OBGYN and go with a midwife and home birth to welcome my son into this world as calming and peacefully as I could. I did chose to go with an unlicensed midwife, as licensing is not required in the state of Oregon, but the greatest mistake of all was not seeing the warning signs for myself. his being my first born I put all my trust and faith into two midwives, who in the end made some bad decisions and proved to be quite negligent. After a full 8 days of labor I delivered my son at home with no heart beat. After all I had done to prepare him for his peaceful arrival, instead of living he rests peacefully….

Well she showed that obstetrician didn’t she? She “ditched” him for an unlicensed midwife AND labored for 8 days AND at no point called for an ambulance to take her to the hospital where her her baby could have been saved with an “unnecesarean.” Now she’s a birth warrior … with a dead baby.

And of course, there is the usual willful blindness on the part of many commentors including Nichol Miller-Doula:

I had a dear friend have a similar situation happen, baby lost at birth and the community rallied around her w/o blame seeking and I believe it helped her. I just hate to see this tragedy spread to ruin the lives of women who may have not been willfully negligent, to cause legislation that would disallow women choices in birth, or create situations where our currently birth friendly state becomes less so.

If I could I would ask doula Nichol Miller:

Exactly how many babies have to die before you get the point that homebirth is dangerous. You’ve already heard of two. Does it need to be 20? 50? What will it take for you to figure out the obvious?

Do you really think that our priority should be the feelings of the midwives as opposed to their competence?

How many dead babies is it worth to make sure that women have choices?

And what choices are we talking about anyway? The choice to let your baby die at the hands of grossly undereducated, grossly undertrained, utterly incompetent unlicensed women who “enjoy” birth?

By my informal count, this is the 8th preventable homebirth death that I have written about so far this year, and that doesn’t count the deaths on Hurt by Homebirth. That means that there have already been twice as many homebirth deaths as should occur in the entire country in an entire year!

The old adage is true:

There are none so blind as those who will not see.

Homebirth advocates point to the Netherlands as an example of a country where homebirth is popular and safe, but Dutch women think otherwise. The Dutch homebirth rate, which has been falling for decades, continues its decline.

As reported in Dutch News:

Professor Jan van Lith of Leiden University’s teaching hospital told the paper media reports about the high perinatal death rate in the Netherlands were driving women to chose hospital births. The increase in demand for pain relief is also playing a role, he said.

In other words, Dutch women find the hospital (and obstetrician care) to be safer and more comfortable.

It’s not merely that perinatal death rates in the Netherlands are relatively high. The truly amazing fact is that Dutch midwives caring for low risk patient at home or in the hospital have HIGHER death rates than Dutch obstetricians caring for high risk women in the hospital.

That was the finding of the study Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: prospective cohort study published in a November 2010 issue of the British Medical Journal. The study was undertaken to investigate why the Netherlands has one of the highest perinatal mortality rates in Europe. The results of the study were nothing short of astounding:

Of the 60 antepartum stillbirths, 37 occurred in primary care and 23 in secondary care…

Twenty-two intrapartum stillbirths and 14 delivery related neonatal deaths occurred. Infants of pregnant women at low risk had a significantly higher risk of delivery related perinatal death (relative risk 2.33, 1.12 to 4.83), compared with infants of women at high risk whose labour started in secondary care under the supervision of an obstetrician. Infants of women who were referred to secondary care during labour had a 3.66 times higher risk of delivery related perinatal death than did infants of women who started labour in secondary care (relative risk 3.66, 1.58 to 8.46)…

That means that low risk women under the care of a midwife had more than DOUBLE the chance of perinatal death than high risk women being cared for by obstetricians.

This finding puts the results of the Dutch homebirth study into an entirely different light. Homebirth advocates are quick to cite Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births as evidence that homebirth is safe because mortality rates at midwife attended births were the same whether they took place at home or in the hospital. But as several commentors pointed out at the time, the mortality rate in both locations (approximately 1/1000) was much higher than would have been expected for a low risk birth. For comparison, consider that low risk midwife attended hospital births in the US have a mortality rate of only 0.4/1000.

So what the Dutch homebirth study REALLY showed is that Dutch midwives have higher than expected rates of perinatal mortality at home AND in the hospital. Hardly an endorsement of either homebirth or midwifery.

Interestingly, health insurance companies report that the decrease in homebirth has not increased health care costs because women are willing to pay an out of pocket fee in return for the perceived increase in safety, not to mention the option of effective pain relief in labor.

This ought to be an object less for homebirth advocates. In the country with the highest rate of homebirth in the industrialized world, neither homebirth nor midwifery provides the lowest risk. That is only found in the hospital under the care of obstetricians. Dutch women know this and the popularity of homebirth has declined dramatically as a result.

When I was in training, someone told me that lay people judge doctors by the three A’s:

Affability
Availability
and last and definitely least
Ability

I was reminded of that while read that Barbara Herrera, Navelgazing Midwife, is shocked, shocked to learn that Robert Biter, MD, aka “Dr. Wonderful,” was not what he seemed.

So, I guess I’m eating huge troughs of crow right now. Embarrassed that I supported someone who seemed so genuine, who really seemed to care about women’s rights in birth. And while he might believe he does, when one sets up another human being for the possibility to die from neglect, I have a really hard time understanding where that person… Dr. Biter … is coming from.

Herrera acknowledges:

… [E]ven as we marched for him in front of the hospital that booted him, stories began emerging about his lackadaisical care, his stretching of the boundaries of safety in homebirths and eventually, I sat and listened as new moms relayed stories that made my toes curl …

Funny. That’s not how I remember it. Herrera was chief among the many women (including Ricki Lake and Rixa Freeze) competing to defend his behavior. As I wrote at the time in Why do natural childbirth advocates participate in their own humiliation?:

Barb Herrera, Navelgazing Midwife, has just written an astounding post that sets a new standard in enabling a “Dr. Wonderful”. You can read the piece here. Barb acknowledges that Dr. Biter is currently facing 6 malpractice lawsuits; she confirms that Dr. Biter was reinstated only so that he could resign and avoid the consequences of a suspension; she glosses over the fact that Dr. Biter, her friend and colleague, never bothered to tell her about those lawsuits or the truth about the reasons for his suspension; she proudly declares that Dr. Biter is giving his approval to what she writes on his behalf. And then … she ignores that information in order to continue to support the man that just abetted her public humiliation.

This is not the first time that something like this has happened. Dr. Stuart Fischbein is still receiving the support of natural childbirth advocates even after his conviction for sexual exploitation of a patient.

Why do NCB advocates routinely participate in their own humiliation, defending indefensible behavior on the part of male obstetricians?

It’s because judge doctors by the three A’s. They fixate on affability and willingly close their eyes to everything else. It’s because NCB emphasizes process at the expense of outcome; the Dr. Wonderfuls are more than willing to collude in such beliefs because their outcomes are often less than ideal. It’s because NCB advocates are desperate for praise and affirmation. They will unquestioningly accept the behavior of any male obstetrician who unquestioningly accepts their unscientific, untested methods of practice.

There is a lot that Herrera and her cohorts could learn from this shameful, completely avoidable episode:

1. When obstetricians with unorthodox methods have unsuccessful outcomes, NCB advocates should ask themselves whether the unorthodox methods are to blame, not conclude that the unorthodox methods have made them targets of unwarranted suspicion.

2. When a Dr. Wonderful loses his privileges, they should wait to find out why, not automatically assume that it is personal retaliation.

3. They should find out the malpractice history of the Dr. Wonderful. Any obstetrician who faces 6 lawsuits after less than 10 years of practice should raise alarm bells.

4. When a Dr. Wonderful is convicted of sexual exploitation, they should drop him like a rock.

5. They should never give money to a Dr. Wonderful who solicits from his patients.

6. They should never give money to charity set up by a Dr. Wonderful if the money is to be deposited in his personal bank account.

7. NCB and homebirth advocates need to look within themselves and figure out why they are so easily conned by any male obstetricians who flatter them, and why they cannot recognize that flattery for what it is, a transparent effort to drum up business and hide professional and personal transgressions.

Finally, NCB and homebirth advocates need to start judging practitioners, whether obstetricians or midwives, by their professional abilities, and recognize that affability is not the best way to choose a provider.

It’s hard to fight a battle of wits with those who are unarmed.

I wrote Twelve things you shouldn’t say to Dr. Amy … unless you want to appear very foolish to save people time, trouble and embarrassment.

Most of what natural childbirth and homebirth advocates think that “know” is factually false. That’s why they continually parachute in to “inform” me about one or more of those 12 false claims and then are chastened to find that the claims aren’t true and that they have been hoodwinked.

Evidently I’ve done a good job choosing the claims. Despite more than 700 comments on the post and countless pages of comments about the post on other blogs and message boards, I haven’t yet seen anyone challenge the accuracy of my claims.

I had hope to save them embarrassment, by allowing them to find out that they had been duped without having to publicly reveal their gullibility, but they are bound and determined to ignore Mark Twain’s famous admonition: “It is better to keep your mouth closed and let people think you are a fool than to open it and remove all doubt.”

Now they parachute in to offer comments so blisteringly inane that it is difficult to believe that anyone could be so poorly informed, not only about science and statistics, but about what constitutes a logical argument or a meaningful rebuttal.

It’s time to get back to basics. In addition to the 12 erroneous factual claims, I’d like to offer a few more things that you shouldn’t say to me unless you want to show that you have literally no idea how to construct a logical argument.

1. You are mean.

That is not an argument or a rebuttal; therefore, it has no place in any discussion of the false factual claims. It is a logical fallacy known as an ad hominem, an attack on the person, not the argument.

2. You are really mean.

For reasons that I cannot begin to comprehend, NCB and homebirth advocates actually think this is an impressive retort when it has been pointed out to them that “you are mean” is not an argument. It’s not an argument or rebuttal, either.

3. Dr. Amy is no longer licensed.

This is a more subtle version of the ad hominem, but it has a slightly different implication. It implies that if I did hold an active license, I would not write what I do. It is both ludicrous and a little pathetic.

It’s ludicrous because the implication is that obstetricians who are licensed disagree with me, and the reality is that I represent mainstream (if not slightly liberal) obstetric thought.

It’s slightly pathetic because the fact that celebrity NCB and homebirth advocates have NEVER had a license to practice obstetrics (or in many cases, have no license or even education in practicing anything) seems never to have even crossed the minds of those who triumphantly point out that my license is not active.

4. I’m glad you’re not my doctor.

Me, too! But that isn’t an argument.

And, my personal favorite:

5. The commentors on your blog who agree with you are really just you in disguise.

I love this one, because it demonstrates so clearly and so succinctly how illogical and uneducated NCB and homebirth advocates often are.

It’s illogical because the accuser has obviously made it up, without making any effort to determine if it is true. It is a window into the “thought process” of NCB and homebirth advocates. They make up stuff that appeals to them without reference to the copious evidence and data that they could access if they bothered, but they don’t bother.

Ironically, it is very easy to determine whether someone is posting as someone else, particularly on this blog. First, you can check the comment history of any individual by clicking on their current screen name. If they have posted other comments from the same computer under other screen names, you can see it. Second, you can often see the IP address (the unique signature of the individual computer) after the screen name. If the comment comes from a different IP address, it comes from a different computer.

Evidently, figuring that out is hard; throwing unsubstantiated, bizarre accusations is easy.

The bottom line is that if you plan to contribute one of these 5 things to the discussion, don’t bother. They don’t constitute an argument or a rebuttal. To the extent that they mean anything, they are just a tacit admission that my factual claims are true and that you can’t find any evidence otherwise.

We understand the problem: the VBAC (vaginal birth after cesarean) rate is too low. It’s time for a bold solution. We need a “VBAC Court.”

VBAC is a safe option for most women, and almost 3/4 of women who opt a VBAC will deliver vaginally and avoid another C-section. But we also know that approximately 0.8% of women attempting VBAC will end up with a ruptured uterus, a catastrophic complication that threatens the life of both baby and mother. And we know that 10% of these babies will die or experience severe neurologic impairment.

In other words, 0.08% of babies will die or be profoundly brain damaged. It is a small risk, on the order of many other risks accepted in pregnancy. Why are the other risks accepted, and the risk of VBAC increasingly considered unacceptable by malpractice insurers, hospitals and obstetricians (who are often at the mercy of malpractice insurers and hospitals who set the rules under which they work)?

There are two main reasons:

1. We KNOW that some babies will die or be left brain damaged. Only 0.08% of babies (80/100,000) sounds like a small number until you consider how many women are suitable VBAC candidates. Nearly 400,000 women have repeat C-sections each year. Not all are candidates for VBAC, but most are. With a liberal VBAC policy, therefore, we KNOW that more than 200 babies will die or be rendered brain damaged each and every year.

2. In each and every one of those deaths, attempted VBAC will be the definitive proximate cause of death or injury. Therefore, there is no way to legally defend these cases. And despite the fact that women sign elaborate informed consent agreements prior to attempting a VBAC, when disaster occurs, many sue and claim that they didn’t really understand the risk, and they win.

Not surprisingly, malpractice insurers, hospitals and obstetricians do not want to deliberately take on the KNOWN risk that some proportion of babies WILL inevitably die or be left brain damaged by a VBAC, and they will be left open to major lawsuits and multimillion dollar payouts.

It sounds like an insoluble problem until you consider that it is not the only problem of this type. It is almost exactly the same dilemma faced by vaccine manufacturers. They make a product that saves lives on a massive scale, but we KNOW that a tiny percentage of children who receive vaccines WILL die or be rendered neurologically impaired. The parents will sue and they will win because, the vaccine is the proximate cause of the death or disability. Vaccine manufacturers announced that they would simply stop producing vaccines because of inevitable lawsuits.

The government stepped in and created the Vaccine Court.

Though it is knows as the “Vaccine Court,” it is, in reality, the Office of Special Masters of the U.S. Court of Federal Claims. Its creation rests on the premise that some deaths from vaccines are inevitable and that lawsuits are a cumbersome, inefficient means of addressing that reality. The Vaccine Court is a form of no-fault insurance. It allows parents and children to receive compensation for death and injuries without filing a lawsuit. It allows vaccine manufacturers to continue supplying vaccines without defending lawsuits over the vaccine reactions that we KNOW will result in a small amount of deaths each year.

The Vaccine Court is part of the Vaccine Injury Compensation Program:

On October 1, 1988, the National Childhood Vaccine Injury Act of 1986 created the National Vaccine Injury Compensation Program (VICP). The VICP was established to ensure an adequate supply of vaccines, stabilize vaccine costs, and establish and maintain an accessible and efficient forum for individuals found to be injured by certain vaccines. The VICP is a no-fault alternative to the traditional tort system for resolving vaccine injury claims that provides compensation to people found to be injured by certain vaccines…

The Vaccine Court works. Each year tens of millions of dollars are paid out to the few families affected by vaccine related death or neurologic injury.

It’s time for a VBAC Court, for the exact same reasons that the Vaccine Court was created. VBAC, like vaccination, is public health good. A liberal VBAC policy would reduces unnecessary surgeries, surgical complications, and health care costs. A VBAC Court, by instituting a no fault program for the VBAC related deaths and injuries that we KNOW will occur, will indemnify hospitals and doctors against lawsuits in the same way that the Vaccine Court indemnifies vaccine manufacturers against lawsuits. VBACs will be readily available, just as vaccines are now readily available.

Frankly, I see no other solution to the problem. Malpractice insurers, hospitals and doctors cannot and will not take on the massive liability posed by VBAC. There is currently no way to accurately predict which women will suffer a uterine rupture during VBAC and there is no accurate prediction method on the horizon. Future developments may reduce the number of babies who die or are left neurologically impaired by VBAC, but that number will never be zero.

If we want to increase the VBAC rate — and patients, doctors and health insurers very much want to increase the VBAC rate — we have no choice but to institute a no fault compensation plan.

It’s time for a VBAC Court.

It’s one of the dirty little secrets of midwifery care in countries in which midwives provide primary obstetrical care. Midwives are often responsible for a disproportionate share of deaths.

As I noted in A stunning indictment of midwives in the Netherlands, a study in the BMJ in November 2010 produced a deeply shocking result:

We found that delivery related perinatal death was significantly higher among low risk pregnancies in midwife supervised primary care than among high risk pregnancies in obstetrician supervised secondary care. This difference was even greater among the cases that were referred from primary to secondary care during labour… (my emphasis)

Now the latest triennial review of maternal deaths in the UK reveals that midwives are responsible for a major proportion of maternal deaths. Indeed, the problem is so worrisome, that an entire chapter is devoted to the role of midwives in maternal deaths.

The report, Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer: 2006–2008, was compiled by the Centre for Maternal and Child Enquiries. Chapter 13 is devoted to the role of midwifery in maternal deaths.

During this triennium, a total of 261 women died from Direct or Indirect causes. In 31 of the 107 Direct deaths (29%), the midwifery assessors considered midwifery care to be substandard, as well as in 27 of the 154 (16%) Indirect deaths. This gives a rate of 22% overall for the 261 women who died of Direct and Indirect causes …

As a general matter, maternal deaths in developed countries occur overwhelmingly among women who are high risk patients. Midwives, of course, care only for low risk patients. Therefore, it is unexpected and disturbing that nearly 1/3 of women who died from direct pregnancy complications were under the care of midwives, and more than 15% of deaths from indirect causes (pre-existing medical conditions) occurred under a midwife, who, by the rules of the UK system, should not have been caring for the patient in the first place.

Why are midwives presiding over so many maternal deaths? Midwives failed to:

• Carry out, record and act upon basic observations for both women at low and higher risk of complications.(emphasis in the original)
• Recognise and act on symptoms suggestive of serious illness, including sepsis …
• Provide pregnant women and new mothers with information about the prevention and signs and symptoms of possible genital tract sepsis …
• Assess the mother’s risk adequately throughout the continuum of pregnancy and the postnatal period, re-assessing as needed if circumstances change.
• Refer and escalate concerns to a medical colleague of appropriate seniority…

In other words, midwives, charged with the care of low risk women and referral of high risk women, did not act upon evidence of complications.

In a remarkable passage, the authors note:

It was evident from some of the situations reviewed for this Report that midwives need to develop clear boundaries between advocacy and collusion. There were instances where midwives should have taken a supportive but challenging approach to ensure that women received appropriate care that was in the best interests of themselves and their babies.

Midwives colluded with patients in pretending that high risk situations were not high risk.

Midwives failed to refer low risk patients who became high risk. For example:

A woman in the postnatal period … reported having felt unwell for a week with symptoms of breathlessness and pain on breathing; she also had swelling in one leg and calf and thigh pain. She was advised by the midwife to attend hospital or a walk-in centre. Some hours later she arrived at the Emergency Department where she collapsed, was intubated, ventilated and transferred to the Intensive-Care Unit. A diagnosis of pulmonary embolism/deep vein thrombosis was made. She went on to have several cardiac arrests later that day. She continued to deteriorate and died some days later.

In addition:

… Similar lessons can be learned from some of the 25 Indirect deaths where the women were booked for midwife-led care. Some of these women who died had co-morbidities that were either missed by the midwife or deemed to be unimportant.

That bears repeating: 25 mothers died of pre-existing medical conditions that the midwives failed to diagnose or understand!

The authors note:

There were many examples of failure to make or act upon basic observations. For instance, a woman with several risk factors for pre-eclampsia arrived at hospital with a fully dilated cervix and promptly gave birth. She was given Syntometrine and, over the next few hours, was observed to have at least four abnormal features symptomatic of pre-eclampsia. These were not acted upon until she suffered a cerebral haemorrhage as a result and died.

The authors point out that these deaths could have been prevented by “getting the basics right.”

Midwives are the experts in the care of healthy, low-risk women. They have a clear duty, however, to be equally skilled in the recognition of early signs of problems and to make prompt referral for appropriate senior medical input.

The chapter concludes:

If there is a single ‘take-home’ message for midwives it is this: listen to the woman and act on what she tells you.

I would go one step further and point out that the relentless “promotion of normal birth” has distorted midwifery. The only thing that should be promoted is the health of mothers and babies. It is grossly inappropriate to promote a process at the expense of outcome. When you privilege process over outcome, as contemporary midwifery theory does, women and babies die.

Lay people often imagine that doctors are entirely independent. They can do whatever they want in the way of medical care, whenever they want in whatever way they want. Nothing could be further from the truth. Doctors are constrained by practice guidelines, insurance company policies and legal sanctions. No where is that more apparent than in the case of vaginal birth after Cesarean, known as VBAC.

VBAC activists like to portray obstetricians as agents of evil who arbitrarily deprived women of the option for VBAC because it was “easier” or “better” for them. The reality is that obstetricians are just as unhappy as patients over the tremendously diminished access to VBAC and they have been working to figure out how to provide easy access to VBAC and comply with practice guidelines, hospital policies and legal penalties. Hence the 2010 NIH conference on VBAC and the recent publication of an entire issue of Clinics in Perinatology devoted to recapping and expanding upon the issues raised at the conference.

The chapter VBAC: A Medicolegal Perspective by Bonanno et al. is one of the best and most concise explanations of the problem that I have read:

What are the fundamental reasons why many hospitals and physicians are no longer performing VBACs? The answer is undoubtedly risk of adverse outcomes and subsequent litigation…

What kinds of adverse outcomes?

As James R. Scott, MD, aptly put in his editorial for the recent conference publication, “VBAC is essentially a uterine rupture issue.” The greatest morbidity from TOLAC for mothers and infants clearly arises from uterine rupture. According to the recent conference statement, the risk of uterine rupture for women who undergo a trial of labor at term is 778 per 100,000 (0.778%), compared with 22 per 100,000 (0.00022%) for women who undergo a repeat cesarean at term…

For patients who have a uterine rupture, what is the likelihood of neonatal death or neurologic injury? Approximately 6% of all uterine ruptures will result in perinatal death…

Okay, but obstetrics is filled with decisions that may lead to the death or neurologic injury of babies. What is different about VBAC?

the primary reason for litigation in obstetrics is the neurologically compromised child, which seems to hold true for VBAC cases. A major difference from the non–VBAC-related cases of neurologically impaired infants is that the proximate cause for the adverse neurologic outcome in most VBAC cases is generally uterine rupture.

In other words, in most cases of neonatal death or injury, there are a variety of possible causes, some that could have been avoided by the obstetrician, others that are out of the obstetricians’ control. In the case of VBAC, however, the cause is always the decision to attempt a VBAC instead of performing an elective repeat C-section. There is no possible legal defense for an obstetrician or hospital. The malpractice insurer simply has to hand over the money, sums that may run into the millions of dollars.

What is the bottom line for providers of TOLAC [trial of labor after Cesarean]? They could potentially be involved in a lawsuit in which a large settlement is paid, even if the standard of care was met.

The simplest choice for obstetricians, hospitals and malpractice insurance providers would have been to ban VBAC outright. No attempted VBACs mean no preventable uterines ruptures means no lawsuits that are impossible to defend. But obstetricians did not want to stop offering VBAC, so they hedged them around with practice guidelines meant to ensure safety and reduce the potential for lawsuits even if a bad outcome occurred. The compromise position was to require that obstetricians and anesthesiologists be “immediately” available when any VBAC patient was in labor. The reasoning is based on the fact that the standard requirement that obstetricians and anesthesiologists be “readily available” for emergency C-section, subsequently defined as within 30 minutes, is not fast enough to prevent neonatal death and disability from uterine rupture.

Why the difference in standards? Because the decision to attempt VBAC is 100% elective and, therefore, uterine rupture during VBAC is a 100% preventable complication. Yes, massive abruption, cord prolapse and severe fetal distress can be equally devastating, but none are preventable, and therefore, the decision to assume those risks is not elective at all.

Okay, but since the decision belongs to the patient, doesn’t and,the reside with the patient. Evidently not.

…In the setting of adequate informed consent, in which the standard of care was met for the management of a patient undergoing TOLAC, and for which all events were sufficiently documented in the medical record, will providers still be subject to successful lawsuits? Unfortunately, the answer is yes.

Where does that leave us? The authors draw the sad, but inescapable conclusion:

The ultimate solution to the VBAC dilemma will clearly not be found within the current system. Medical courts, tighter regulation of medical experts, dispute resolu- tion, and no-fault regulation have all been described as potential ways to make the system more efficient, more equitable, and ultimately more supportive of families who need financial support regardless of whether the injury was a result of medical negligence…

In other words, the solution will not be found by blaming, pressuring or demonizing obstetricians. Obstetricians didn’t cause the problem; doctors can’t fix it.

Silly me! When I first read about the Homebirth Consensus Summit, I thought it was a conference to reach a consensus about homebirth.

After all these years, I should have known better. Homebirth advocates wouldn’t dare to hold a conference where all the data would be presented and varying viewpoints aired. At such a conference, the copious data showing that homebirth increases the risk of neonatal death would be presented. Awkward!

At such a conference the CDC statistics showing that homebirth with an American homebirth midwife (CPM) triples the rate of neonatal death would be presented. Really awkward!

At such a conference, the pathetically inadequate requirements for CPM licensure might come up. Really, really awkward!

What to do? Hold a conference where only the only people who can participate must agree with the consensus beforehand. Phew, dodged that bullet.

On the Summit website, buried among the obfuscations, the real goal of the Summit is apparent, as well as the way that the Summit sponsors plan to get to that goal.

The Home Birth Consensus Summit will assemble a diverse multidisciplinary group of individuals with the goal of discussing a common agenda for the provision of home birth services in the United States. (my emphasis)

And if that’s not clear enough:

The point is not to debate the “rightness or wrongness” of homebirth. The goal is to establish what the whole system can do to support those who choose homebirth, and provide the care, safety net, consultation, collaboration and referral necessary to make homebirth the safest and most positive experience for all involved-moms, babies, families, communities, health care workers, hospital personnel, administrators, payors, and so on.

The rightness or wrongness of homebirth? What does that mean? It is doublespeak for the safety of homebirth. They couldn’t simply say, “The point is not to debate the safety of homebirth” because that would leave open the possibility that it isn’t safe. Awkward!

So anyone who wants to create a consensus around the provision of homebirth care is welcome? No, of course not. Only those vetted for agreement with the predetermined outcome of the Summit could possibly be allowed to attend.

The invitation selection process has been an iterative process with many rounds of vetting, internally and externally. Many individuals were nominated … Short lists were created by multidisciplinary subcommittees chaired by the Vision Team members who were most familiar with representatives of certain stakeholder groups. Each subcommittee went through a detailed vetting and weighing process and considered the balance of perspectives, ethnicities, gender, age, geography and other factors… We also prioritized those who were likely to respect the process by fully engaging in open-minded dialogue.

So the only participants can be those who were invited and you can only be invited if the “Vision Team” knows you, knows what you are going to say and and knows that you won’t bring up any issues that the team would prefer to hide. Anything else would be awkward.

It’s pretty clever when you think about it. The “Vision Team” wanted to hold a meeting about homebirth without mentioning the safety of homebirth. Since safety is the single most important issue, that is quite a challenge. The only way to make sure that it provides the predetermined “consensus” is to have only invited participants who are undergo “many rounds of vetting” to be absolutely, positively sure that they won’t provide any information isn’t pre approved, any perspective that isn’t pre approved, and above all else, any of that pesky data that homebirth advocates don’t want women to see.

Anything else could be very, very awkward.

The media is to blame for the pain of childbirth!

That’s the new meme in the world of natural childbirth and it is getting a great deal of play. Childbirth is not inherently painful; its depictions in popular media like TV shows and movies tricks women into believing that childbirth is painful. Hence the otherwise inexplicable preoccupation on NCB blogs with how childbirth is portrayed in specific TV shows and movies.

The meme has received positive attention from all the usual suspects: the Lamaze blogs, Rixa Freeze, Midwifery Today, and even RH Reality Check. Australian midwife Lisa Barrett has been doing an ongoing series called “Absurd Birth Scenes” exploring each TV show or movie in depth.

On the surface, it sounds intriguing, cutting edge and thought provoking. In reality, it is the same dreary sexism masquerading as midwifery theory. You know those silly women! They can’t be trusted to perceive their own pain. It’s all in their heads. They’re all hysterical … and we know that hysteria, a form of emotional reaction based on distorted thinking, starts in the uterus.

That must be it, since no one is exploring how any other form of severe pain is an illusion fostered by the media. I haven’t noticed any documentary movies (direct to DVD or otherwise) that investigate how it doesn’t really hurt to have an anvil dropped on your head and we only think it does because it appears to hurt Wile E. Coyote in Looney Tunes.

And no one suggests (or would dare suggest) that men’s pain is an illusion fostered by the media. I haven’t seen any theories that men getting kicked in the groin don’t really experience severe pain but only think they do because of the way that America’s Funniest Home Video’s portrays getting hit in the groin by a baseball.

This is just the modern iteration of Grantly Dick-Read’s profoundly racist and sexist claim that primitive (i.e. black) white have painless childbirth. Childbirth pain is an artifact of cultural indocrination. The new version is that primitive women (i.e. those who aren’t exposed to Western media) have painless childbirth. Childbirth pain is (you guessed it) an artifact of media indoctrination.

The concept received its ultimate exegesis in the direct to DVD film Laboring Under an Illusion. The title explicitly claims that childbirth pain is nothing more than an illusion. According to the movie website:

Anthropologist Vicki Elson explores media-generated myths about childbirth. As a childbirth educator for 25 years, she observes daily how our culture affects our birth experiences.

An anthropologist? Not really. Just a childbirth educator who studied “the anthropology of childbirth pain” at the University of Massachusetts.

There is an area of study known as the “anthropology of pain” but the anthropology of childbirth pain differs from it in one major respect. In all other areas of pain anthropology, it is the experience and meaning to the sufferer of pain that is studied. No anthropologist suggests that the pain itself does not exist.

For example, there are studies of the anthropology of the pain of female genital mutilation: how and why women and men in cultures that practice FGM believe that the pain is necessary. And there are studies about the anthropology of the pain associated with extreme sports: how and why women and men are willing to endure the extreme pain of marathon running, for example. However, there are no studies that I could find that argued that female genital mutilation is not inherently painful, or that the pain described by marathon runners does not really exist.

Childbirth pain is real. It’s meaning may be culturally mediated, but the pain itself is no more culturally mediated than the pain of being kicked in the testicles. The primary purpose of this ridiculous claim is to justify the existence and high fees of “childbirth educators” and the self-aggrandizing rhetoric of natural childbirth advocates. Many lie about the pain, lie about what works to ease the pain, and lie about the benefits and risks of pain relief in labor. It is ultimately nothing more than self-serving posturing. More lies = more money; more lies = more admiration (or at least self-admiration).

The original theory of “natural” childbirth espoused by Grantly Dick-Read was a racist and sexist lie. This updated theory of childbirth pain is the same sexist lie with the racism stripped out. Both are premised on the same claims: women’s perceptions of pain cannot be trusted; the pain is all in their heads; if only women were “educated,” they would not have pain in childbirth. It was a disgusting and demeaning theory then; it is a disgusting and demeaning theory now.