It seems like every day a new visitor parachutes in to this blog and attempts to “educate” me. Inevitably, the visitor finds that almost everything she says is false. Indeed, almost everything she thinks she “knows” is false. So to spare these visitors embarrassment, and to reach those who are attempting to “educate” me on other blogs, I have compiled the following list. Here’s what you should not say to me, and why you should not say it.

1. The US does very poorly on infant mortality.

Infant mortality is the WRONG statistic. It is a measure of pediatric care. That’s because infant mortality is deaths from birth to one year of age. It includes accidents, sudden infant death syndrome, and childhood diseases.

The correct statistic for measuring obstetric care (according to the World Health Organization) is perinatal mortality. Perinatal mortality is death from 28 weeks of pregnancy to 28 days of life. Therefore it includes late stillbirths and deaths during labor.

The US has one of the lowest rates of perinatal mortality in the world.

2. The Netherlands, which places the greatest reliance on midwives, has low mortality rates.

No, the Netherlands has, and has had for some years, the HIGHEST perinatal mortality rate in Western Europe. It also has a high and rising rate of maternal mortality. The Dutch government is deeply concerned about these high mortality rates and a variety of studies are underway to investigate.

The most recent study published in the BMJ is early November 2010 revealed and astounding finding. The perinatal mortality rate for low risk women cared for by midwives is higher than the perinatal mortality rate for high risk women care for by obstetricians!

3. Obstetricians are surgeons.

I never understand how anyone has the nerve to say this to me. I AM an obstetrician. No one knows better than I what obstetricians are or are not. I went to college. I went to medical school. I spent four years in obstetric training. I delivered thousands of babies. I have cared for thousands of gyn patients. That some doula who is a high school graduate thinks that she can possibly know more than I about the nature of obstetricians defies belief.

Obstetricians do surgery as part of their practice. That does not make them surgeons. If it did, ophthalmologists and dermatologists would be surgeons too, since they do surgery as a routine part of caring for their patients. Is anyone seriously suggesting that you cannot go to an ophthalmologist for an eye exam because he or she will recommend unnecessary surgery?

4. Homebirth is safe.

No, all the existing scientific evidence and all national statistics indicate that homebirth triples the rate of neonatal death. Even studies that claim to show that homebirth is as safe as hospital birth, like the Johnson and Daviss BMJ 2005 study, ACTUALLY show that homebirth with a CPM has triple the rate of neonatal mortality of comparable risk women who delivered in the hospital in the same year.

The Midwives Alliance of North America (MANA) is well aware that homebirth is dangerous. That’s why they are hiding their own mortality rates. They spent almost a decade collecting information on more than 18,000 CPM attended homebirths, announcing at intervals that they would use the data to show that homebirth is safe. So why haven’t any of us seen it?

The data is publicly available, but ONLY to those who can prove they will use the data for the “advancement” of midwifery. MANA is quite up front about the fact that they will not let anyone else know what they have learned. Obviously, if homebirth had been anywhere near as safe as hospital birth, they would be trumpeting it from the mountain top. It does not take a rocket scientist to suspect that their data shows that homebirth dramatically increases the risk of neonatal death.

5. Homebirth midwives are experts in normal birth.

This one always makes me laugh. Experts in normal birth? That’s like a meteorologist who claims to be an expert in good weather.

I guess they’re trying to make a virtue of necessity. Homebirth midwives know virtually nothing about the prevention, diagnosis and management of pregnancy complications. That’s a problem when you consider that the only reason you need a birth attendant is to prevent, diagnose and manage complications. You don’t need any expertise to catch the baby and make sure it doesn’t hit the floor. Ask any taxi drive; he’ll tell you.

6. Childbirth is safe.

No, childbirth is INHERENTLY dangerous. In every time, place and culture, it is one of the leading causes of death of young women. And the day of birth is the most dangerous day in the entire 18 years of childhood.

Why does childbirth seem so safe? Because of modern obstetrics. Modern obstetrics has lowered the neonatal mortality rate 90% and the maternal mortality rate 99% over the past 100 years. What has the contribution of midwifery been to lowering those mortality rates? Zero? They’ve invented nothing, discovered nothing and tested nothing that has had any impact on perinatal or maternal mortality.

7. Childbirth used to be dangerous but that is only because sanitation was poor and women were poorly nourished.

No, the great advances of sanitation occurred in the 1800’s and the early years of the 1900’s. Not surprisingly, this had a big impact on deaths from infectious causes. However, rates of perinatal and maternal mortality did not begin to drop appreciably since the late 1930’s and the discovery of antibiotics. In the intervening years, easier access to C-sections, epidural anesthesia, newer and better antibiotics, blood banking, and neonatology led to dramatically lower mortality rates.

8. C-section increases the risk of maternal and neonatal death.

No, women who die in pregnancy are most commonly women with serious pre-existing medical illness (heart disease, kidney disease) or serious pregnancy complications (pre-eclampsia). C-sections are often done in an effort to save the lives of these women. Sometimes it is not enough. The C-section is what is known as a “confounding factor.” Both the C-section and the death can be traced back to the mother’s health status; the C-section did not cause the death.

MacDorman and colleagues have attempted to show that C-sections for “no indicated risk” increase the neonatal death rate. Their papers have been roundly criticized because they used birth certificates, not hospital record. Unrelated investigations of birth certificates have shown that, while they are highly reliable for data like weight and Apgar scores, they are highly unreliable for risk factors. Indeed, unrelated studies have shown that up to 50% of women who have serious medical illnesses like heart disease, have those risk factors missing from the birth certificate.

9. Induction harms babies.

No, induction lowers perinatal mortality. The yearly CDC data on births shows that as the induction rate has risen, the rate of late stillbirth has dropped by 29% and the neonatal death rate has not increased.

10. If childbirth were dangerous, we wouldn’t be here.

This represents a profound lack of knowledge about evolution as well as a profound lack of knowledge about childbirth. Evolution does not lead to perfection. Evolution is the result of the survival of the fittest, not the survival of everyone. Human reproduction, like all animal reproduction, has a massive amount of wastage. Every woman was born with millions of ova that will never be used. Every man produces billions of sperm that will never fertilize an ovum. Even when a pregnancy is established, the miscarriage rate is 20%. That’s right. One in five pregnancies dies and is expelled and yet we are still here. Human reproduction is perfectly compatible with a natural neonatal death rate of approximately 7% and a natural maternal death rate of approximately 1%.

11. US maternal mortality is rising.

Despite a rather histrionic political report from Amnesty International making that claim, US maternal mortality is not rising and has even dropped in both of the past two years. Why does it look like it has risen? Because the standard death certificate has been revised twice in the past two decades in order to more accurately capture maternal deaths. The new death certificate has revealed maternal deaths which otherwise would not have been counted. There is no evidence that maternal deaths have increased; it’s merely that reporting of those deaths has improved.

12. Women are designed to give birth.

Women are not “designed”: they have evolved and evolution involves trade offs. Babies with big heads tend to be more neurologically mature, so having a big neonatal head has evolutionary advantages. A small maternal pelvis makes it easier for a woman to walk and run, providing her with an evolutionary advantage. Those two advantages are often incompatible. The woman with a small pelvis may have been able to survive by outrunning wild animals, but when it came time to give birth, she was more likely to die because that small pelvis could not accommodate a large neonatal head.

***

The above statements have two things in common. First, they are wrong. Second, they are passed back and forth between natural childbirth advocates who “teach” each other they are true. That’s why it is impossible to become “educated” by reading natural childbirth books and websites. Most of their information is flat out false, and they are entirely insulated from scientific evidence. Natural childbirth advocates make up their “facts” as they go along. They don’t read the scientific literature. They don’t interact with science professionals. Indeed, professional natural childbirth advocates take special care to never appear in any venue whether they might be questioned by doctors or scientists. They know they’d be laughed out of the room. That’s okay with them as long as there is a large pool of gullible women out there who will believe them and buy their products.

It is important that those who are parachuting in to “educate” me understand that they literally have no idea what they are talking about. Most of what they think they “know” is factually false. And they demonstrate that every time they utter one or more of those twelve statements.

That’s not a typo.

Natural childbirth originated with the publication of Grantly Dick-Read’s book, Childbirth Without Fear, but in the intervening years, NCB advocates have made fear the centerpiece of their philosophy. Not fear of childbirth, despite the fact that is is inherently dangerous for babies and mothers. And not fear of pain; evidently only losers, the weak and the unempowered, fear pain. No, the centerpiece of natural childbirth philosophy, and its chosen and most potent marketing tool, is fear of doctors.

This strategy makes tremendous sense from a marketing point of view. After all, who is going to buy the services of someone who hectors you to avoid pain relief when you are in agonizing pain (a doula) unless you are afraid of something “worse”? And who is going to let her precious baby be delivered by a high school graduate who knows nothing about science and thinks gems have “energy” and flowers having healing “essences” (a CPM, a certified “professional” midwife) unless she is convinced that the alternative is “worse”? Who is going to waste hundreds of dollars on goofy ideas that rarely if ever work, like Hypnobabies, unless they are told that without it, they might actually break down and listen to those evil doctors?

Craig Thompson, professor of marketing at University of Wisconsin wrote about this tactic in Consumer Risk Perceptions in a Community of Reflexive Doubt the in the September 2005 Journal of Consumer Research. Thompson marveled at the ability of homebirth advocates to market a “product” by directly defying common sense:

Advocates of natural childbirth seek to inculcate reflexive doubt by countering two commonsense objections to their unorthodox construction of risk: (1) medicalized births would have never gained a cultural foothold if they were so risk laden and (2) the medical profession would not support obstetric practices that place laboring women at risk.

In other words, it is absolutely critical to the natural childbirth project to convince women that doctors don’t know what they are doing, and willfully and cheerfully risk the lives of women and babies to promote a secret agenda.

How do doctors promote that secret agenda?

… [T]he cultural dominance of medicalized childbirth is explained as the historical artifact of a fin de siecle struggle between midwives and physicians, where the latter group held a decided economic and sociocultural advantage. As this critical narrative goes, the medical profession leveraged its emerging economic-political clout and cultural affinities toward ideals of scientific progress and technological control to displace midwives (both socially and legally) as the authoritative source of childbirth knowledge.

Obviously, the only people who will believe such clap-trap are people who know nothing about history, childbirth or science. That’s why it is absolutely imperative for natural childbirth advocates to hid the fact that in the 100 years after its advent, modern obstetrics dropped the neonatal mortality rate 90% and the maternal mortality rate 99%.

Only if women don’t know that modern obstetrics has been so spectacularly successful can they be convinced that technological intervention serves no other purpose than to allow doctors to show off.

Through this cultural shift, the obstetric profession also imposed medical preferences for heroic, technological interventions on the birth process. Childbirth reformers interpret these innovations—such as forceps deliveries—as unnecessary intrusions whose primary function was enabling physicians to display technical skill.

Wait! It gets even worse:

… [O]bstetricians are trained in a technocratic model of labor management that has been institutionalized through hospital protocols and technological systems. This technocratic model is condemned for treating pregnancy and labor as a mechanistic process in which the woman’s body is fraught with treacherous design flaws that necessitate the administration of corrective technologies. As a result, women are routinely subjected to the unintended consequences of a cascade effect, whereby one technological intervention creates a problem that must be managed by yet another. The driving cautionary tale, oft repeated in the natural childbirth literature, is that the labor process can be so disrupted by this escalating series of technological interventions that a C-section becomes medically necessary.

The message, integral to natural childbirth advocacy is clear: Obstetricians can’t help women because their technology is useless (except in the rarest of circumstances). Obstetricians don’t want to help women; they want to make money, show off, and get to their golf games as quickly as possible. In fact, obstetricians actually want to HURT women by imposing their fancy technologies to ruin otherwise perfect labors simply so that they can apply even more technology. And (this is the big finish), the only way you can prevent obstetricians from victimizing you, hurting you and profiting from you is …. to buy our NCB products!

You need to buy books and visit websites, because if you don’t you will have no idea that you are lamb being led to the medical slaughter. You need to pay for classes and tapes to gain the fortitude to resist the apparently helpful intentions of doctors and nurses to prevent complications and even death. You need to pay a layperson to stay with you during labor to be sure that you don’t succumb to those apparently helpful medical professionals. And for the truly committed, you need to pay a high school graduate who is “trained” in normal birth (kind of like a meteorologist who is trained in forecasting only good weather) to do basically nothing except call 911 and disappear if things go wrong.

That’s a tall order when you consider that for women with health insurance, childbirth in the hospital costs almost nothing. NCB advocates must convince you to spend tens of dollars on books, hundreds of dollars on classes, and thousands of dollars for the company of women who are incapable of doing a blessed thing if complications occur. Very few women would hand over that kind of money unless they had been convinced to fear the medical professionals who can help them without expecting a cash payment.

Make no mistake: NCB advocates must work hard to market their product and thereby make a profit. They must fill women with misinformation about childbirth and keep those same women ignorant of what science actually shows. They must train women to suspect that those who seem to have good intentions secretly have only sinister intentions. Better yet, they must convince women to be belligerent in demeanor and obnoxious in their demands so that there is no possibility that they will form trusting relationships with their doctors.

Simply put, NCB advocates must create an alternative universe entirely unmoored from the reality of childbirth dangers, unmoored from scientific evidence, and unmoored from the truth that people in the helping professionals are actually trying to help.

The stakes are high. If NCB advocates do not successfully create a culture of fear and suspicion, no one will pay money for their books and courses, or pay thousands of dollars for what are essentially lay companions with no particular knowledge of childbirth and a function restricted to inculcating fear of anyone who does have knowledge.

When it comes to natural childbirth, follow the money. Without fear, NCB advocates won’t make money. Therefore every woman must be convinced to approach childbirth with fear.

Have you noticed that the word literally has actually come to mean its opposite, figuratively? According to Dictionary.com, literally is the adverb form of literal, defined as:

in accordance with, involving, or being the primary or strict meaning of the word or words; not figurative or metaphorical

But consider the following sentence: I heard a crash from my son’s room and I literally flew up the stairs. Did the speaker actually fly? Of course not; she used the term as if it were an audible exclamation point, to provide emphasis and to garner attention. The truth is that the speaker figuratively flew up the stairs, but she is trying to emphasize how frightened she was and how quickly she responded.

This example highlights an ongoing problem in communication, the promiscuous use of language. By that I mean the use and abuse of language for the express purpose of drawing attention. The example above is trivial. Yes, the speaker changed the meaning of a word to imply its opposite, but no listener believes that the speaker actually flew.

It’s more problematic, however, when the speaker deliberately intends to convey a meaning far different than the actual meaning of the word. Such is the case with the promiscuous use of the term rape as in the currently fashionable accusation of “birth rape”.

Childbirth activists use the term “birth rape” for the same reason anyone promiscuously uses language: to garner attention. They don’t like certain practices in modern obstetrics; they’ve whined and complained and tried to pretend that they represent the majority of women, but no one is paying much attention to them.

They’ve figured out that “I didn’t like the way the obstetrician treated me when he was trying to save my baby’s life” is not particularly compelling, since anyone who has ever suffered a serious medical problem knows that doctors give priority to saving lives in life threatening situations, rather than respecting emotional sensitivities. Let me be very clear about this point: I’m not saying that doctors are right. Often more compassion could be shown without compromising life saving efforts in the least. I’m merely pointing out that this is nothing more than a commonplace occurrence in our society.

Birth activists are dismayed that no one is particularly moved by their complaints. So they’ve decided to ratchet up the stakes by promiscuously using the word rape.

What is the actual definition of rape?

the unlawful compelling of a woman through physical force or duress to have sexual intercourse.

The legal definition has been expanded to include other forms of sexual touching that do not involve intercourse. And while it is true that we have come to understand that rape is often more about power than sex, we limit the meaning of rape to sexual contact. We have a different word for non-sexual harm; that word is assault. This is a critical point. We don’t discount any form of abuse or harm, but we do insist on precision in describing and punishing it.

Crying “birth rape” is just a more toxic example of the abuse of the word literally. The accuser is not claiming to be literally raped and meaning instead figuratively raped. She’s going one step further. She’s claiming that she was literally, actually raped. And she justifies this promiscuous use of the word rape by insisting that the only thing relevant fact is her feelings. If the victim “feels like” she has been raped, then she has been raped.

But we do not determine whether a crime has occurred by referencing the feelings of the victim. The feelings of the victim matter not at all; what matters are the “feelings” of the perpetrator. We a name for the perpetrator’s feelings: intent.

All crimes require more than a physical act. They require intent, legally known as mens rea or the guilty mind. Consider the crime of murder. A person run down by a driver who was texting is every bit as dead as a person run down by a professional hit man intending to cause the death. But only the latter case is murder, while the former is manslaughter at most. Intent is absolutely critical to determining whether a crime has been committed and what type of crime has been committed.

It does not matter how the victim feels about the crime (or in the case of murder, how the victim theoretically would feel about the crime). It does not matter that the relatives of the victim run down by a texting driver “feel like” the victim has been murdered, and that’s not because we discount their feelings. We are actually quite sympathetic to the anger and sense of loss of the victim’s relatives.

Let’s look again at “birth rape.” Rape requires sexual touching. A man can punch a woman and it is not rape. It might be assault, but it is not rape. Why? Because it is not sexual touching.

And it’s not merely a matter of the identity of the body part that has been touched. A woman can kick a man in the crotch, but that is not rape either. It might be assault, but it is not rape. Why? Because intent matters.

The victim’s feelings about the matter are irrelevant. The woman who was punched can “feel” like she was being raped, but that doesn’t make it so. A man who was kicked in the crotch might “feel” like he was being raped, but that doesn’t make it so.

What are the implications for the accusation of “birth rape”? Simply put, there is no such thing as “birth rape.” The accusation is merely the promiscuous use of the word rape with the express intent of drawing attention to one’s self or one’s cause.

It does not matter that the self-proclaimed victim was treated roughly. It might be assault, but it is not rape. Why? Because it is not sexual touching.

It does not matter that the part of the body involved has a sexual function. Why? Because intent matters.

And most importantly, it does not matter what the victim feels. Her feelings may be relevant to her; and, of course, they may be critical in providing psychological help to her. But they are entirely IRRELEVANT to the determination of whether or not a rape has occurred.

“Birth rape” does not exist. It is a promiscuous abuse of the term rape for the sole purpose of garnering attention. The term is legally meaningless and ethically suspect. It is morally wrong to insist that a rape has occurred when nothing of the kind happened. It is ethically unjustified to misuse the term rape regardless of how worthy the motivation. And it is insupportable to base the accusation of a crime on how the victim “feels” about it.

It is ironic that one of our greatest technological advances has provided an incomparable boon to scientific illiteracy. I’m referring, of course, to the internet. Prior to the advent of the internet, wacky pseudo-scientific “theories” were relegated to the fringes and had to be deliberately sought out. Now pseudo-scientific mumbo jumbo can be widely disseminated.

But perhaps more important than the actual dissemination of misinformation is that feeling of validation that internet communities provide. Pseudoscience can thrive when believers congregate on message boards that validate bizarre beliefs and ban information that undermines those beliefs. They don’t call it validation, though; that’s too clinical. They call it “support.”

Hart et al. explore this phenomenon in their paper Feeling Validated Versus Being Correct: A Meta-Analysis of Selective Exposure to Information. The authors explain:

… Receiving information that supports one’s position on an issue allows people to conclude that their views are correct but may often obscure reality. In contrast, receiving information that contradicts one’s view on an issue can cause people to feel misled or ignorant but may allow access to a valid representation of reality. Therefore, understanding how people strive to feel validated versus to be correct is critical to explicating how they select information about an issue when several alternatives are present. (my emphasis)

Avoiding cognitive dissonance is central to the search for validation:

… According to dissonance theory, after people commit to an attitude, belief, or decision, they gather supportive information and neglect unsupportive information to avoid or eliminate the unpleasant state of postdecisional conflict known as cognitive dissonance.

Minimizing cognitive dissonance requires selective exposure, seeking out information sources that confirm existing beliefs and avoiding sources that undermine those beliefs. For example:

In one of the initial studies testing selective exposure, mothers reported their belief that child development was predominantly influenced by genetic or environmental factors and then could choose to hear a speech that advocated either position. … [M]others overwhelmingly chose the speech that favored their view on the issue.

There is an exception, however. People were happy to view uncongenial information if they felt it was easy to refute.

Internet communities that promote pseudoscience are quite overt in their preference for validation over accuracy. Consider this reminder that appears at the top of the Mothering Unassisted Childbirth Forum:

… This is a forum for support, respectful requests for information, and sharing of ideas and experiences. While we will not restrict discussions only to those who birth without professional attendants, proselytizing against UC will not be permitted…

Mothering is even more overt in its insistence on selective exposure to information about vaccination:

… Though Mothering does not take a pro or anti stand on vaccinations, we will not host threads on the merits of mandatory vaccine, or a purely pro vaccination view point as this is not conducive to the learning process.

They’re not anti-vaccine but they refuse to print a pro-vaccine point of view? Whom do they think they are kidding? Of course, it’s hardly surprising if the primary purpose of the forum is to provide readers with validation, rather than to transmit accurate information.

The authors and publishers of pseudoscience books and websites are quite upfront about their determination to minimize cognitive dissonance by restricting the free flow of information. Only information that supports a predetermined point of view is allowed. Anything else must be deleted. To the extent that any real scientific papers are discussed, they are limited only to those that can be easily refuted. The rest of the vast scientific literature is ignored.

That’s why it is impossible to become “educated” when reading pseudoscience websites.

Homebirth advocates are like celebrity pundits. TV and print pundits make predictions about elections, stock market behavior, and the expected results of international diplomacy, yet they never, ever review whether their predictions were correct. That would be embarrassing since they are often wrong. Instead they simply move on to new predictions.

Homebirth advocates go them one better. They do review their decisions and improbably declare that the wrong decisions were actually right, or right at the time, or right because it wouldn’t have made any difference. It does not matter how spectacularly wrong they were; they stubbornly, pigheadedly, childishly insist that they were right.

Consider this discussion on the website of celebrity homebirth advocate Ricki Lake.

Amie writes:

Hello ladies, I am 41 + 1 today and my midwife has suggested that I see her OB for induction. I have no effacement, no dilation and the baby has not completely dropped so she feels that it is in my best interest to have a hospital birth. I have been taking orally and inserting the prime rose, walking, having lots of sex and have taken castor oil and nothing has helped. I am not comfortable with being medically induced but would rather try that then have a repeat cesarean… I still want to stay far away from an epidural but am afraid that the pitocin will make the contractions too powerful and will limit me to my bed.

Here are the replies.

Sheila:

… I also was overdue with my VBAC attempt (41 wks 3 days) and induced with pitocin. But my body wasnt ready, and I had another csection for failure to progress. If you and baby are fine, refuse intervention…

Jennifer:

You may not be “41 weeks” exactly. And 40 is only an average. All of my babies were born at 41.5 weeks; dates based on ultrasound measurements in early pregnancy. I was 44 weeks according to the calendar…

Meredith:

… My mother was over 44 weeks when she had my sister (he first birth), she was 43 weeks when she gave birth to me and 41 weeks when she had my younger sister. So women just carry longer and it’s completely natural…

Sara:

… Induction itself is a slippery slope to many, many medical interventions including c-sec. It keeps your body from going through the natural chemical process that helps you handle the pain…

Trust you body, follow your intuition. I am sending you lots of “labor dust” 🙂

***

Instead of addressing the real issue, the increased risk of stillbirth as a pregnancy advances, the replies offer such gems of wisdom as ‘I ignored my doctor and my baby didn’t die’ and ‘maybe you are not really postdates.’ Of course no homebirth “advice” would be complete with the immature magical thinking that is intrinsic to homebirth advocacy: ‘follow your intuition.’

Amie responds:

Thank you so much for all of the info. I honestly feel like he is not ready and all of my castor oil milkshakes and walking are not helping because of that fact…

Amie’s update 42+1 weeks:

Well the OB appt went well, I had an NST and an ultrasound. The fluid levels still look good and the heartbeat was beautiful… I have an appt on Thursday with the midwife and hopefully I will have some dilation by that point. Thank you for all of your encouragement, it has really helped me.

Amie’s update 43 weeks:

My son Evan was still born by cesarean section… OB said that the cord had clotted and was in knots. It has been a very hard time for me as I am second guessing all the decisions I made throughout the pregnancy…

***

It is appropriate that Amie is second guessing her decisions since her decisions directly led to the preventable death of her baby. She was told that she was at increased risk for a stillbirth and she ignored that information.

What about the folks at Ricki Lake’s website who “advised” her. They’re not second guessing their “advice” at all. They appear to be delusional.

Susan:

… I am glad that you know you are not to blame, and are not wasting time and energy on second-guessing your decisions.

Meredith:

… You did and fought for, what you knew in your heart, to be the best path and never second guess that.

Irene:

… please don’t blame yourself in any way, you did what any other Mom would have done!

***

Only among homebirth advocates is the road to death “the best path” and the choices that led to that death “what any other Mom would have done.”

Here’s a bit of unsolicited advice: When the baby dies after you tell someone that their baby won’t die, have the decency to be embarrassed. You’ve already demonstrated that you were spectacularly wrong. Don’t compound it by pretending, against all the evidence, that you were right.

Regular readers know that among all the supposedly “natural” childbirth practices, I reserve special contempt for unassisted birth. Unassisted childbirth (and its companion, unassisted pregnancy) involves shunning medical care of any kind, even a lay midwife. Known by afficianados as freebirth or UC, it is perhaps more accurately called stuntbirth. As I have written in the past:

… Advocates emphasize the fact that it is transgressive, is “authentic”, values process over outcome, creates a sense of belonging, and produces feelings of empowerment.

Unassisted childbirth has no benefit to the baby and poses very serious risks to both the baby and the mother. It involves no particular skill, a belief that no expertise in childbirth is needed, has a prime objective of testing the capacity to endure pain, and risks death as the likely outcome of a mistake. In short, it is nothing more than a stunt.

Both of the leading advocates of UC have lost babies as a result. American Laura Shanley claims that she had 4 wonderful unassisted births, but she has actually had 5. She deliberately and knowingly gave birth to a premature baby alone at home and, over the next several hours, watched him die.

Last year, Australian Janet Fraser gave birth to an baby who had died during labor. In the weeks leading up to the birth, Fraser had proudly boasted to an Australian paper that she had no prenatal care of any kind, and planned to have no medical assistance at the birth. Her baby paid the ultimate price for her inane ideas.

This week the inevitable happened. Both the baby and the mother died at an unassisted birth. I learned from two separate unrelated sources of the tragic death of a first time mother who died within hours of delivering a stillborn baby. The reports indicate that the mother died suddenly and without apparent warning. It’s not clear if this means a sudden event like an amniotic fluid embolus or an ongoing medical complication like pre-eclampsia or hemorrhage that went unrecognized by the couple. An autopsy is being performed.

It is a horrible, senseless and needless tragedy.

Homebirth and midwifery advocates point with pride to a recent study that showed that homebirth with a midwife in the Netherlands is as safe as hospital birth with a midwife (Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births). They tout this study as evidence that homebirth is as safe as hospital. A new study suggests an entirely different explanation: Dutch midwives have unacceptably high rates of perinatal mortality both at home and in the hospital. Indeed, the perinatal mortality rate for LOW risk women cared for by Dutch midwives is HIGHER than the perinatal mortality rate for HIGH risk women cared for by Dutch obstetricians!

The new study, Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: prospective cohort study, appears in this week’s issue of the British Medical Journal. The authors explain that the study was undertaken to investigate why the Netherlands has highest perinatal mortality rate in Europe.

Several factors are mentioned as possible explanations for this high mortality, such as differences in registration and maternal characteristics of the Dutch childbearing population, restricted management of premature babies, and the absence of standard screening for congenital anomalies. The numbers of older mothers, multiple pregnancies, and mothers belonging to an ethnic minority are relatively high in the Netherlands. However, this can only partly explain the high perinatal mortality. Whether the Dutch obstetric care system contributes to this relatively high mortality remains unclear.

This is an important question because the Dutch system of maternity care relies primarily on midwives and those midwives perform a relatively high number of homebirths. This study, a cohort study of severe morbidity and mortality of term fetuses or neonates, called ATNICID (Admission of Term Neonates to Intensive Care or Intrauterine Death), was begun in 2007 with the express intent of examining the relationship between the organization of the Dutch maternity care system and the high rate of perinatal mortality.

The study ultimately enrolled 37,735 term infants without congenital anomalies:

16,672 (44.2%) infants of nulliparous women (including 143 (0.9%) twin pregnancies) and 21,063 (55.8%) infants of multiparous women (including 226 (1.1%) twin pregnancies). Data on 91 (0.2%) infants were missing; we excluded these from further analysis… 18,686 (49.5%) infants were born to women who started labour in primary care as low risk, of whom 5492 (29.4%) were referred to secondary care during labour; 13,194 (35.0%) infants were born under the supervision of a midwife in primary care, and 24,450 (64.8%) infants were born under the supervision of a gynaecologist.

The results were 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)…

A total of 210 infants were admitted to the NICU:

… resulting in an overall incidence of admission to NICU of 5.58 (4.83 to 6.33) per 1000 live births…. Half of the women (51%, n=107) started labour in primary care. Of these, 70% (n=75) were referred to secondary care during labour… The incidence of admissions to the NICU was 2.43 per 1000 term births in primary care, 13.7 per 1000 term births if referral to secondary care during labour occurred, and 5.45 per 1000 term births managed exclusively in secondary care.

Nearly half the NICU admissions were the result of one cause: asphyxia. Among the 17 infant deaths:

71% (n=12) [were] because of asphyxia and 29% (n=5) because of an infection. Fourteen cases were classified as directly related to circumstances during labour.

Of the 26 deaths related to labor presided over by midwives, 65% were attempted homebirths.

These results are deeply shocking.

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. Unfortunately, we were unable to adjust for confounding variables because we used aggregated data from a large birth registry database. However, the results are unlikely to have been overestimated, because risk factors such as low socioeconomic status, higher age, or non-Western ethnicity were more prevalent among the women at high risk. (my emphasis)

The authors express their concern:

In summary, the Dutch obstetric care system is based on the assumptions that pregnant women and women in labour can be divided into a low risk group and a high risk group, that the first group of women can be supervised by a midwife (primary care) and the second group by an obstetrician (secondary care), and that women in the primary care group can deliver at home or in hospital with their own midwife. When complications occur or risk factors arise antenatally, during labour, or in the puerperium in primary care, the women is referred to secondary care. We found that the perinatal death rate of normal term infants was higher in the low risk group than in the high risk group, so the Dutch system of risk selection in relation to perinatal death at term is not as effective as was once thought. This also implies that the high perinatal death rate in the Netherlands compared with other European countries may be caused by the obstetric care system itself, among other factors. A critical evaluation of the obstetric care system in the Netherlands is thus urgently needed.

In contrast to the claims of homebirth and midwifery advocates, the Netherlands is far from being the ideal model of obstetric care. The Netherlands has the highest perinatal mortality in Europe, and midwifery care may very well be the cause of this calamity.

I suppose you can’t expect much from someone who admits that her entire career is based on an article she read in the National Enquirer.

My introduction to waterbirth was an article in the National Enquirer of all places! Can you imagine basing two and a half decades of work for mothers and babies on that sensational news rag??

But Barbara Harper asserts the safety of waterbirth with such breathtaking stupidity that even I am shocked. That she believes she can get away with it tells me that she assumes that her followers are gullible fools. Given her popularity, she may just be right.

Harper is surely aware that babies drown at waterbirth. She must be aware that Ireland suspended waterbirths when baby Harry Eccles died of brain damage caused by drowning. She cannot possibly be ignorant of the fact that the waterbirth babies are born directly into the equivalent of toilet water that has been contaminated with fecal material. She must know that the American Academy of Pediatrics (AAP)has declared that waterbirth is not safe for babies. She is betting on the fact that her supporters don’t know about the waterbirth deaths, don’t understand that the water is contaminated with dangerous microorganisms and aren’t aware of the pronouncements of the AAP.

Harper clearly thinks that keeping her followers ignorant of dangers of waterbirth is justified. But I can’t fathom what led her to believe that she could simply make up scientific sounding gobbledy gook and pass it off as “facts.”

Purveyors of pseudoscience take note: when it comes to spewing stupidity, Barbara Harper is in a class by herself. Consider the following, taken from Harper’s explanation of Waterbirth FAQs:

What prevents baby from breathing under water?

There are four main factors that prevent the baby from inhaling water at the time of birth:

1. Prostaglandin E2 levels from the placenta which cause a slowing down or stopping of the fetal breathing movements. When the baby is born and the Prostaglandin level is still high, the baby’s muscles for breathing simply don’t work, thus engaging the first inhibitory response.

2. Babies are born experiencing mild hypoxia or lack of oxygen. Hypoxia causes apnea and swallowing, not breathing or gasping.

3. Water is a hypotonic solution and lung fluids present in the fetus are hypertonic. So, even if water were to travel in past the larynx, they could not pass into the lungs based on the fact that hypertonic solutions are denser and prevent hypotonic solutions from merging or coming into their presence.

4. The last important inhibitory factor is the Dive Reflex and revolves around the larynx. The larynx is covered all over with chemoreceptors or taste buds. The larynx has five times as many as taste buds as the whole surface of the tongue. So, when a solution hits the back of the throat, passing the larynx, the taste buds interprets what substance it is and the glottis automatically closes and the solution is then swallowed, not inhaled.

Every word in that explanation is a lie, with the possible exception of “and” and “the.” And it’s not merely a collection of lies. It is a collection of strikingly stupid lies, to boot. Either the woman is an idiot, and she thinks her followers are idiots, or both.

Let’s look at each claim individually.

1. Prostaglandin E2 causes a slowing down or stopping of the fetal breathing movements.

This is both a lie and irrelevant. It is a lie because there is not a single study on humans or animals to support it. It’s irrelevant because fetal breathing movements (practice breathing in the womb) are NOT the source of a baby’s initial drive to breath. Lack of oxygen and build up of carbon dioxide stimulate neonatal breathing.

2. Hypoxia causes apnea and swallowing, not breathing or gasping.

Another bare faced lie. Hypoxia (lack of oxygen) makes it MORE likely that a infant will try to breath, not less.

3. So, even if water were to travel in past the larynx, they could not pass into the lungs based on the fact that hypertonic solutions are denser and prevent hypotonic solutions from merging or coming into their presence.

Oh, the stupid, it burns!

I guess Harper figured the use of the word “hypertonic” would impress her followers and trip them up. In chemistry, the suffix “tonic” refers to the concentration of electolytes and other dissolve components of cellular fluids. Isotonic is the the same concentration as cellular fluids; hypertonic means higher concentration (such as seawater), hypotonic mean lower concentration (such as freshwater).

The water in the tub at waterbirth is hypotonic; that much is true. All the rest is a giant lie. Lung “fluid” (whatever that is supposed to be) is isotonic, not hypertonic. The tonicity of a fluid has NOTHING to do with what can be mixed with it. Seawater is hypertonic. Fresh water is hypotonic. According to Harper, you couldn’t add freshwater to a cup of seawater because the seawater would prevent the solutions from merging. You don’t even have to try that experiment for yourself to know that Harper is babbling nonsense.

4. The last important inhibitory factor is the Dive Reflex.

Another lie. Harper is four for four!

The dive reflex exists, but it is not operating during waterbirth. The dive reflex is the reason that people sometimes survive long immersion in icy water. The extreme cold suppress breathing and slows down heart rate, decreasing the body’s need for oxygen. The dive reflex works in COLD water, not warm water, and, of course, the water in the birth pool is warm, not icy cold.

The bottom line is very simple. Barbara Harper is a mendacious fraud. She lies and she spreads stupidity. Tragically, many women believe her.

I just came across this surprising comment from Dr. Michael Klein, an emeritus professor of family practice, and a prominent critic of rising C-section rates. He is explaining how inductions prevent stillbirth and why we should ignore that life saving technique because natural labor is best:

Now, anxiety looms very large in childbirth, and a lot of people like to induce because it reduces this anxiety and makes their lives easier. And what’s this anxiety about? Stillbirths. We don’t like those. But you’d have to induce one thousand women to prevent one stillbirth, and people just don’t get their minds around that. If you induce one thousand women and prevent one stillbirth but have a 40 percent c-section rate, what have you done?

Let’s look first at Dr. Klein’s numbers. Dr. Klein intimates that preventing 1 perinatal death per thousand is trivial, but it’s not. In a low risk population, the late perinatal mortality rate is less than 3 per thousand. So even 1 addition death dramatically raises the perinatal death death rate. That’s hardly trivial.

Moreover, Dr. Klein seems to be suggesting that a C-section rate of 40% among women means that 40% of induced women have unnecessary C-sections. The latest data, however, seems to indicate that induction double the C-section rate. So out of that 40%, 20% were going to have C-sections anyway for unrelated reasons. And of course if a woman is having an induction for medical indications related to an increased risk of stillbirth (post dates, high blood pressure, poor fetal growth), it is likely that her baby is also at risk for intrapartum complications necessitating a C-section, regardless of whether or not she was induced. A more accurate representation, then is that saving one baby’s life may lead to 100-200 unnecessary (in retrospect) C-sections.

Let’s restate Dr. Klein’s question more accurately: If you induce one thousand women and prevent one stillbirth but do 100-200 unnecessary (in retrospect) C-sections, what have you done?

What have you done? I think the answer is obvious. You’ve saved a baby’s life!

What Dr. Klein is actually saying is this: it’s worth letting babies die in order to lower the C-section rate.

Now Dr. Klein is certainly entitled to his opinion, but I’d like to see him explain it to a mother whose baby died just so he can boast about his low C-section rate.

“Yes, Mrs. Jones, your baby is dead, but think of what we’ve accomplished. You’ve had a natural labor, and I am quite sure that natural labor is best. But that’s not all! You’ve saved lots of other women from having an unnecessary (in retrospect) C-sections and you’ve allowed me to maintain my low C-section rate.”

I suspect that Mrs. Jones is not going to derive much consolation from that explanation. And while Dr. Klein might garner praise from natural childbirth advocates for maintaining a low C-section rate, other doctors will consider him foolish at best and thoroughly cynical at worst. No doctor is impressed with a low C-section rate bought at the price of preventable infant deaths. Anybody can lower his C-section rate if he is he content to let babies die.

But what I’d really like to see Dr. Klein do is tell it to the judge (at the malpractice trial, of course).

“Yes, judge, I completely agree with plaintiff’s counsel that I could have prevented the death of Mrs. Jones’ baby by offering her induction at 42 weeks.”

“You agree?”

“Of course, it would be foolish to deny it. If I had induced Mrs. Jones her baby would be alive and healthy today, but I think we have accomplished something more important.”

“More important than saving a baby’s life?”

“Sure, Mrs. Jones avoided a C-section. We’ve demonstrated that natural labor is better. “

“Better? Better than what?”

“Better than a C-section that might have turned out to be unnecessary in retrospect. And that’s not all, judge. Think of the 100 or more women who got to experience natural labor AND took home a live baby.”

I doubt the judge will be impressed. But perhaps Dr. Klein can dazzle him with his “big picture thinking.”

… And the uterine scar left after a c-section has great consequences for the next birth. You’re more likely to have placenta previa or an invasive placenta, more likely to need another c-section, have an ectopic pregnancy, be infertile, and have a stillbirth. Now look what happened — we induced the first birth to prevent a stillborn, and now the second pregnancy is more likely to end in stillbirth. The thought process that leads to an induction is not big-picture thinking.

Let’s look at the big picture, and increase Dr. Klein’s cohort from 1,000 to 100,000. Using Dr. Klein’s numbers, 100,000 inductions would save the lives of 100 babies and lead to 10,000-20,000 additional unnecessary (in retrospect) C-sections. Studies of stillbirth after C-section show and increased relative risk anywhere from 0-1.5. At a late stillbirth rate of 3/1000, that would mean an increased stillbirth rate of 4.5/1000 or an excess of 1.5 stillbirths/1000.

If 20,000 women had unnecessary (in retrospect) C-sections, we would expect an extra 30 stillbirths if everyone in that group had a subsequent pregnancy. What’s the big picture? The worst case scenario (assuming a high relative risk of stillbirth in subsequent pregnancies, and a subsequent pregnancy rate of 100%) is that in saving 100 existing babies in current pregnancies, we would theoretically put at risk a maximum of 30 babies in future pregnancies. So the big picture is a net saving of the lives of 70 babies.

Let me be very clear. I’m not suggesting that an even one unnecessary C-section is desirable. I would be the first one to promote any technique that improved our ability to accurately detect babies in distress and thereby avoid unnecessary C-sections. But until such technology arrives, we must work with what we have. And what we have a system that leads to unnecessary C-sections but saves substantial numbers of lives in the process. As I explained in a recent post, the induction rate is rising and perinatal mortality is falling. Therefore, I strongly disagree with Dr. Klein’s rather disingenuous argument; a natural labor is not best, a live baby is best. Period.