That’s a bizarre question. Obviously breastmilk is food. Why would anyone say otherwise? To get a tax-break, of course.

Lactivists are angry that the Internal Revenue Service has ruled that breastfeeding is not a form of medical care and therefore, breastfeeding supplies such as pumps cannot be purchased with money from tax sheltered health accounts.

According to an article in today’s New York Times, Breast Pumps Lack Tax-Sheltered Status:

Denture wearers will get a tax break on the cost of adhesives to keep their false teeth in place. So will acne sufferers who buy pimple creams.

People whose children have severe allergies might even be allowed the break for replacing grass with artificial turf since it could be considered a medical expense.

But nursing mothers will not be allowed to use their tax-sheltered health care accounts to pay for breast pumps and other supplies.

Why? Because the IRS considers breastmilk to be food, not medical care.

This is nothing new. Breastfeeding supplies have never qualified as medical care, but lactivists and pediatricians were advocating for a change in the rules.

Despite a growing body of research indicating that the antibodies passed from mother to child in breast milk could reduce disease among infants — including one recent study that found it could prevent the premature death of 900 babies a year [debunked here] — the I.R.S. has denied a request from the American Academy of Pediatrics to reclassify breast-feeding costs as a medical care expense.

Perhaps lactivists overreached by dramatically inflating the cost of breastfeeding supplies:

… The cost of buying or renting a breast pump and the various accessories needed to store milk runs about $500 to $1,000 for most mothers over the course of a year, according to the United States Breastfeeding Committee, a nonprofit advocacy group.

That might have been true two decades ago when my oldest children were born, but it is a gross exaggeration now. State of the art double electric breast pumps can run $300 or more, but electric breast pumps can be purchased for under $100 and manual pumping supplies for less.

But the IRS’ stated reason for denying tax sheltered status is the characteristic enthusiastically embraced by lactivists themselves: breastfeeding is natural.

I.R.S. officials say they consider breast milk a food that can promote good health, the same way that eating citrus fruit can prevent scurvy. But because the I.R.S. code considers nutrition a necessity rather than a medical condition, the agency’s analysts view the cost of breast pumps, bottles and pads as no more deserving of a tax break than an orange juicer.

Where does that leave lactivists and breastfeeding mothers? It leaves them free to push for tax breaks for breastfeeding on the grounds that it is a behavior we wish to encourage and we promote tax breaks for all sorts of behaviors we wish to encourage (replacing refrigerators with more energy efficient models, rewarding retirement planning, etc). But pretending that breastfeeding is medical care is not going to work.

When it comes to high profile nutrition studies, Dr. John Ioannidis has some surprising advice: Just Ignore It!

Who is Dr. Ioannidis and why should you listen to him? Dr. Ioannidis was recently profiled in The Atlantic under the provocative title Lies, Damned Lies, and Medical Science. Dr. Ioannides is a physician and meta-researcher. In other words, he is a researcher who studies research.

… He and his team have shown, again and again, and in many different ways, that much of what biomedical researchers conclude in published studies … is misleading, exaggerated, and often flat-out wrong. He charges that as much as 90 percent of the published medical information that doctors rely on is flawed.

Dr. Ioannidis was an early proponent of evidence based meedicine (EBM) a movement designed to regularize medical practice by determining the evidence and then applying it. He quickly ran into a very serious problem:

… Ioannidis was shocked at the range and reach of the reversals he was seeing in everyday medical research… Baffled, he started looking for the specific ways in which studies were going wrong. And before long he discovered that the range of errors being committed was astonishing: from what questions researchers posed, to how they set up the studies, to which patients they recruited for the studies, to which measurements they took, to how they analyzed the data, to how they presented their results, to how particular studies came to be published in medical journals.

It’s not really all that surprising when you consider the rationale behind medical journals. Lay people, and even some scientists, treat publication in a scientific journal as the end of the scientific process. In fact, it’s merely the beginning. Publication in a scientific journal does NOT mean that the paper is true; it merely means that it is worthy of being considered as part of the conversation.

Anyone who has ever read a scientific journal knows that research papers are divided into four parts: introduction, methods, results and discussion. The methods section requires the author to explain exactly what was done and how it was done, with the express purpose of allowing other scientists to repeat the experiment to verify it. The results section must include the actual findings as well as the statistical analysis that led the authors to their conclusions. Again, the purpose is so that other scientists can evaluate whether the data was analyzed using the correct statistical methods. In other words, the underlying assumption is that each and every scientific paper might be wrong and the only way we can know for sure is if we try to repeat the experiment and/or analyze the results for ourselves. It turns out that a lot of scientific papers are nothing more than junk.

Consider high profile nutrition research:

When a five-year study of 10,000 people finds that those who take more vitamin X are less likely to get cancer Y, you’d think you have pretty good reason to take more vitamin X, and physicians routinely pass these recommendations on to patients. But these studies often sharply conflict with one another. Studies have gone back and forth on the cancer-preventing powers of vitamins A, D, and E; on the heart-health benefits of eating fat and carbs; and even on the question of whether being overweight is more likely to extend or shorten your life. How should we choose among these dueling, high-profile nutritional findings? Ioannidis suggests a simple approach: ignore them all.

Why?

… even if a study managed to highlight a genuine health connection to some nutrient, you’re unlikely to benefit much from taking more of it, because we consume thousands of nutrients that act together as a sort of network, and changing intake of just one of them is bound to cause ripples throughout the network that are far too complex for these studies to detect, and that may be as likely to harm you as help you.

Moreover:

… Even if changing that one factor does bring on the claimed improvement, there’s still a good chance that it won’t do you much good in the long run, because these studies rarely go on long enough to track the decades-long course of disease and ultimately death. Instead, they track easily measurable health “markers” such as cholesterol levels, blood pressure, and blood-sugar levels, and meta-experts have shown that changes in these markers often don’t correlate as well with long-term health as we have been led to believe.

That’s why short term studies are often later over turned when the results of long term studies become available:

For example, though the vast majority of studies of overweight individuals link excess weight to ill health, the longest of them haven’t convincingly shown that overweight people are likely to die sooner, and a few of them have seemingly demonstrated that moderately overweight people are likely to live longer.

And caveats don’t even include the errors that often riddle scientific publications:

… ubiquitous measurement errors (for example, people habitually misreport their diets in studies), routine misanalysis (researchers rely on complex software capable of juggling results in ways they don’t always understand), and the less common, but serious, problem of outright fraud…

So where does that leave the average consumer? Dr. Ioannidis’ advice is spot on. When it comes to breathless nutritional claims, ignore them all. Vitamin supplements are generally useless except when treating documented vitamin deficiencies (like scurvy and pellagra), specific foods do not prevent cancer and will not help you to live longer, and just because something is harmful in large amounts does not mean that moderate amounts are moderately harmful (obesity is bad, mild to moderate overweight may actually be good).

Don’t change your eating habits based on the latest research results reported in newspapers. It may be spurious, flat out false or only true in the short term and not over time. Don’t be the first on your block to try the newest supplement or dietary advice. Wait until data has been collected from tens of thousands of people over many years. And above all, don’t mistakenly conclude that because something has been published in a peer reviewed scientific journal, it must be true. Many papers published in scientific journals are nothing more than junk.

The natural childbirth literature is replete with references to informed refusal. Curiously, this same literature does not explain what informed refusal involves, or the type of information a patient might require to be capable of making an informed refusal. Perhaps most importantly, natural childbirth literature counseling informed refusal neglects to mention the most important component: the risks of forgoing treatment.

Consider Judith Lothian’s article Saying “No” to Induction, published in the Journal of Perinatal Education, a publication of Lamaze International. The article is anything but neutral on the issue. The underlying assumption of the article is that induction is not necessary and is done for doctor convenience.

According to Lothian:

… Women are encouraged to appreciate the last days and weeks of pregnancy and to have confidence that when a woman’s body and her baby are ready, labor will begin spontaneously. This information, as well as knowledge of how induction alters the process of normal labor and birth and increases the possibility of having a near-term infant, is the foundation for informed refusal.

Let’s look at the legal definition of informed refusal:

Just as a patient needs adequate information to be able to accept proposed treatment, he or she needs information to be able to decline or refuse it. However, because the informed consent doctrine grew out of the tort of battery, it has not always been clear that a physician has an obligation to provide information in a situation where the patient is forgoing treatment. Truman v. Thomas, decided by the California Supreme Court in 1980, is often cited for the principle of “informed refusal.” Truman held that a physician who recommends a procedure—in that case, a diagnostic Pap smear test—must ensure that a patient who rejects this recommendation understands the consequences of not having the test.

In other words, the foundation of the doctrine of informed refusal is an understanding of the consequences of refusing the intervention. A discussion of the possible disadvantages of the intervention is, of course, part of the process, but it doesn’t meet the basic requirement.

Lothian continues:

… To make an informed decision—either informed consent or informed refusal—women need to know the value of waiting for labor to start on its own. The last days and weeks of pregnancy are vitally important for both the mother and her baby. The end of pregnancy is as miraculous as its beginning. It’s a lot easier to say “no” to induction if the mother knows the essential and amazing things that are happening to prepare her body and her baby for birth.

Fair enough. But Lothian’s discussion of these issues veers from inane to factually false. The inane:

Thinking of, and clinging to, the “due date” as “the day” makes it difficult for women to trust nature’s beautiful plan for the end of pregnancy and the start of labor.

No. Nature is not a person. Nature does not have a “plan,” beautiful or otherwise, and it is quite possible for a pregnancy to “naturally” end in a dead baby. Indeed the risk of stillbirth begins to climb before the due date (40 weeks), and rises dramatically after 42 weeks.

The factually false:

… Pitocin does not cross the blood-brain barrier; therefore, endorphins are not released in response to the increasingly strong and painful uterine contractions. Laboring women do not experience the benefits of endorphins as they try to manage their contractions. Additionally, without the help of endorphins, they are likely to require an epidural…

That’s a bunch of baloney. There is no evidence that pitocin is required to cross the blood brain barrier for endorphins to be produced. There is no evidence that women with higher levels of endorphins have less pain. And there is no evidence that a deficit in endorphins is what leads women to request an epidural.

Lothian goes on to bemoan the potential increase morbidity of early induction (although she has not established that most inductions are done “early”). Curiously, she is entirely silent on the issue of mortality. That’s a rather strange omission considering that the primary reason for induction of labor is usually to prevent a stillbirth from postdates, pre-eclampsia, or other causes. Perhaps she left it out because it completely undermines her case. As the rate of labor induction has risen in the past two decades, the rate of late stillbirth has dropped dramatically. In other words, labor induction appears to do precisely what it is designed to do.

What does Lothian have to say on the benefits of labor induction?

Nature is not perfect. However, when it comes to babies and birth, unless there is a clear medical indication that induction of labor will do more good than harm, nature beats science hands down. For both mothers and babies, it is safe and wise to wait patiently until labor begins on its own.

What are those clear medical indications? Lothian doesn’t say, and if you don’t specify the indications, a woman cannot give informed refusal. It is safe and wise to wait until labor begins on its own? Where’s the evidence for that claim?

Lothian is vague on when induction is appropriate, but she is quite sure that it is the job of childbirth educators to encourage patients to refuse.

Saying “no” to induction and to other interventions that are becoming routine takes courage and confidence, as well as the knowledge that women have the right to informed refusal. What women learn from you about nature’s plan for labor and birth, including the beauty of waiting for labor to start on its own and the risks of interfering without clear medical indication, will insure that the women you teach will have the information they need to confidently say “no” to routine induction.

But “saying no” is not the same thing as informed refusal. Yes, women have to right to refuse treatment, but they can only be informed if they understand the risks. Saying no does not require courage or confidence, nor are courage and confidence remotely relevant when making medical decision. Information is what is required, and Lothian provides precious little. She leaves out the most important piece of information, the mortality rate, and she does not bother to quantify the purported risks.

The law is clear on what is necessary to be informed:

… [The] elements are: the diagnosis; the nature and purpose of the proposed treatment; the risks and consequences of the proposed treatment; reasonably feasible alternatives; and the prognosis if the recommended treatment is not provided.

Lothian provides essentially no information on any of these critical elements. Without them, there is no such thing as informed refusal. There is only petulantly “saying no” and possibly living to regret the consequences.

Garrison Keillor famously explained that all the children in Lake Woebegone are above average. Maybe homebirth and natural childbirth advocates come from Lake Woebegone. They appear to believe that when in comes to childbirth complications, all of them are at below average risk.

Natural childbirth and homebirth advocates like to tell themselves and each other to “trust birth.” They consider it a practical strategy, and appear not to realize that it is a common cognitive error known as “optimistic bias.” Simply put, individuals tend to underestimate their risk of various bad outcomes, regardless of known statistics and often in the face of known risk factors. For example, many smokers rationalize their smoking by estimating that their personal risk of getting lung cancer is much lower than it really is.

The paper Unrealistic Optimism About Susceptibility to Health Problems: Conclusions from a Community-Wide Sample, written by Neil Weinstein, was published in 1986. It has been cited by no fewer than 962 other scientific papers because its descriptions and insights are so important. The article explores different reasons for optimistic bias. Although the paper is not specifically about childbirth, its descriptions and conclusions seem particularly apt in considering the current emphasis among childbirth advocates on “trusting birth.”

There are two sources of optimistic bias that seemly particularly apt in describing the outlook of natural childbirth and homebirth advocates. The first is a cognitive error that is often made in connection with uncommon events:

… Any factor that makes us think our own risk is low could lead us to claim that we are below average in risk if we fail to recognize that the same factor may apply to others as well. From this point of view, hazards rated low in frequency could lead to optimistic biases in comparative risk judgments because we forget that the hazards are just as unlikely to strike our peers. Similarly, lack of experience with a problem may make it difficult to imagine how it might affect us and lead us to claim that our own risk is below average….

When considering the chance of being affected by an uncommon event, NCB and homebirth advocates believe that however uncommon the even is, it is even less likely to happen to them than the average person. They fail to realize that they are average persons.

Second:

… [P]eople use their past experience to predict their future vulnerability. For many hazards, people seem to hold the mistaken belief that if they have not yet experienced the problem, they are exempt from future risk (absent/exempt)… [P]eople may believe that vulnerability is a constitutional matter, so if the problem has not appeared, their bodies must be resistant. Furthermore, some problems may seem to be caused by one’s behavior or personality (e.g., obesity and drug addition), and people may conclude that the absence of a problem at their age means that they do not have the weakness of character that allows it to develop.

This strategy is also favored by NCB and homebirth advocates. They never had a health problem before, so they assume they will not develop a problem during childbirth. They had a successful homebirth in the past, so they assume all future homebirths will be successful. They “eat right” and stay “informed” so they will not be prey to childbirth complications.

Weinstein conducted interviews with almost 300 individuals, evenly divided between men and women. The participants were asked to evaluate their risk of developing each of 32 different conditions. The most remarkable finding is the most basic. Participants judged themselves to be less likely than average to develop virtually every single condition or disease (31 out of 32).

Although respondents believed themselves to be at less risk than average for virtually every event ranging from developing asthma, to breaking a bone, to being mugged, there were difference in how much less they thought they faced.

Consistent with predictions and with previous studies, optimistic biases increase with perceived preventability, with perceived embarrassment, and most strongly, with the belief that one is exempt from risk if the problem has not yet appeared…

Moreover:

Optimistic biases decrease with experience, perceived frequency, and the perceived extent of others’ worry. Optimism was unrelated to perceived seriousness.

In other words, respondents judge their risk of experiencing a bad outcome as markedly lower than average if they thought that they could prevent the outcome, if the outcome was embarrassing, or if they had no personal experience of the outcome. That sounds like an excellent description of NCB and homebirth advocates’ approach to the inherent risks of childbirth. They falsely believe that they have the power to prevent bad outcomes; they will be embarrassed in front of their peers in the NCB or homebirth movement if they have a bad outcome; and they erroneously believe that if they have no personal experience of the bad outcome it isn’t likely to happen to them.

Weinstein found that, amazingly, actual risk factors don’t seem to moderate individuals’ assessment of personal risk:

… Cigarette smoking is a powerful risk factor for many illnesses. It is strongly correlated with subjects’ judgments of lung cancer risk, has a small correlation with risk judgments for heart attack and cancer in general, and has no significant correlation with the perceived risk of stroke. Furthermore, except for frequency of drinking, none of the other behavioral risk factors is correlated with perceived risk. There is no association between auto safety belt use and perceived risk of injury in an auto accident, between excercise or dietary cholesterol and heart disease risk, or between flossing of one’s teeth and vulnerability to gum disease. Even for drinking, the relationship between the behavior and the perceived risk is optimistically skewed. What one finds is that 77% of the people who never drink place themselves in the lowest comparative risk category, but of those who drink alcoholic beverages four or more times a week, only 18% place themselves in any of the above average risk categories. In other words people give themselves credit when they do not drink but do not acknowledge that frequent drinking may place them in a higher than average risk category.

NCB and homebirth advocates practice the same strategy of denial. Twins, breech and VBAC are well known risk factors for bad outcome yet NCB and homebirth advocates (including homebirth midwives) insist that these are not “high risk” situations.

Weinstein concludes:

… The principal characteristics determining the amount of bias elicited by the 69 different hazards that have been considered were (1) the belief that if the problem has not yet appeared, one is exempt from future risk; (2) the perception that the problem is preventable by individual action; (3) the perception that the hazard is infrequent; and (4) lack of experience with the hazard. If a hazard had such characteristics, people had a strong tendency to conclude that their own risk was less than the risk faced by their peers…

Not only do these factors account for individuals’ underestimation of their personal risk, I suspect that the same factors account in large part for the difference in outlook between obstetricians on the one hand and NCB and homebirth advocates on the other. Doctors KNOW that just because a problem has not developed in the past does not mean it can’t happen in the future; doctors KNOW that most pregnancy complications have nothing to do with individual action; doctors KNOW that infrequent events do happen; and, perhaps most importantly, doctors have direct personal experience of these complications occurring in low risk women.

NCB and homebirth advocates like to pretend that doctors “pathologize” birth. The reality is exactly the opposite. NCB and homebirth advocates are in denial about the risk of developing childbirth complications. They trumpet their philosophy of “trusting birth” without having any idea that it marks them as hopelessly ignorant of actual risks, in deep denial about their personal risk, and so naive that they believe that if they haven’t heard of it, it can’t happen to them.

Proponents of “alternative” health have a deeply fraught relationship with scientific evidence. On the one hand, even the most outlandish forms of pseudoscience attempt to invoke the imprimatur of science. Their claims range from the simple (“studies show …”) to the elaborate (lists of scientific citations of papers that appear to support the claims being advanced, but actually do not). On the other hand, when scientific evidence undermines their claims, advocates of “alternative” health suddenly discover that scientific evidence is not “applicable” to their claims or is “not enough” to guide clinical decision making.

As Professor Rory Coker explains:

Pseudoscience appeals to the truth-criteria of scientific methodology while simultaneously denying their validity. Thus, a procedurally invalid experiment which seems to show that astrology works is advanced as “proof” that astrology is correct, while thousands of procedurally sound experiments that show it does not work are ignored…

Something similar plays out in virtually every pseudoscience. Consider vaccine rejectionism. On the one hand, vaccine rejectionists brandish scientific papers that show deleterious effects of various vaccine components like thimerosol or, the current favorite, aluminum. Leaving aside for the moment that the papers are typically not directly relevant (involving related but different chemicals, involving massive amounts as compared to the minuscule amounts present in vaccines), these are real scientific papers containing valid scientific evidence.

But, unfortunately for vaccine rejectionists, there are tens of thousands of scientific papers that demonstrate the safety and effectiveness of vaccines. It is difficult even for vaccine rejectionists to ignore this large body of evidence. In contrast to the scientific papers that they like, this mass of scientific research, is not accepted on its face. When trying to persuade the unsophisticated, scientific evidence is explicitly rejected (“vaccine preventable diseases were decreasing BEFORE vaccines were invented”). If the audience is more sophisticated, a more subtle approach is required. In that case, specific poorly done papers are critiqued, never mind that they aren’t particularly representative of the literature as a whole.

This double standard is deftly summarized by Edzard Ernst MD, PhD, FMedSci, FSB, FRCP, FRCPEd in a brief editorial in the journal he edits, Focus on Alternative and Complementary Therapies (FACT). Prof. Ernst is the bete noire of “alternative” health. His credentials are impeccable. He was the first Professor of Complementary Medicine in the UK. Born and trained in Germany, he began his career at a homeopathic hospital. His belief in “alternative” health was so complete, he set out to show that its various remedies are both safe and effective.

But what he found apparently shook him to the core. His 700 published papers represent a lifetime of research that led him to conclude that only 5% of “alternative” medicine is backed by scientific evidence. The other 95% has either not been studied or has been definitely shown to be ineffective, unsafe, or both. Not surprisingly, Dr. Ernst is now viewed as “the scourge of alternative health.”

Dr. Ernst begins by reviewing the relationship between “alternative” health and evidence based medicine:

I have said it so often that I hesitate to say it again: the concepts of EBM are not a threat but an unprecedented opportunity for CAM [Complementary and Alternative Medicine]. EBM does not focus on mechanisms of action or basic sciences … It merely asks, ‘does it work?’ This open-minded approach is therefore uniquely suited for testing the value of CAM …

Alas:

What I have seen happening recently is almost the opposite. If the results do not fit the preconceived ideas of CAM proponents, the findings tend to be dismissed. In such instances CAM enthusiasts tend to declare the studies in question to be fatally flawed. If trial after trial is negative, the old argument re-emerges … Scientific rationality, they argue, is for testing washing machines and guns but ‘for understanding what passes between humans… [it] is not adequate’…

In other words, there is a double standard:

Rigorous proof, it seems, is the standard for conventional health care, and study designs that cannot possibly generate a negative result are being promoted as the standard that CAM enthusiasts would like to see applied to CAM. Observational data might then masquerade as proof of effectiveness, while unbiased studies are deemed to be not applicable to CAM.

… Scientific testing of CAM is acceptable, perhaps even desirable … but the results have to be positive. If they are not, then the level of scientific rigor is swiftly lowered until finally – BINGO – a (false)-positive result is being generated. Science has thus become a tool not for testing (its true purpose) but for proving that one’s preconceived ideas were correct.

Increasingly, that double standard is being wielded by midwifery and natural childbirth advocates. For example, the recently published Wax study that showed homebirth to have triple the neonatal mortality rate of hospital birth was excoriated by midwives and homebirth advocates for a variety of methodological flaws. Suddenly midwives and homebirth advocates were deeply concerned about sample size, data quality and methodological rigor. Curiously, they have never demonstrated the same concern for the most widely quoted study on homebirth, the Johnson and Daviss BMJ 2005 study, which suffers from such grievous methodological flaws that it is completely invalid.

In other words, midwifery and homebirth advocates follow the playbook for pseudoscience:

If the results do not fit the preconceived ideas of natural childbirth advocates, the findings tend to be dismissed. In such instances NCB advocates declare the studies in question to be fatally flawed. If trial after trial is negative, the old argument re-emerges: evidence doesn’t hold all of the answers.

Rigorous proof is the benchmark for conventional health care. It is not the benchmark in NCB advocacy. Scientific research is acceptable, but the results have to be positive. If they are not, then the level of scientific rigor is swiftly lowered until finally the desired (but false) result is achieved. Science has thus become a tool for proving that one’s preconceived ideas were correct… And that’s a double standard.

Dead babies are difficult to sweep under the rug. Everybody notices.

The standard strategy of homebirth advocates is to claim that homebirth is as safe as hospital birth. They point to poorly done studies published by those with a vested interest in promoting homebirth. They compare mortality rates at homebirth with high risk hospital birth. They point to international comparisons of infant mortality (which is a measure of pediatric care, not obstetric care). You can fool lots of laypeople with that misinformation, but it’s not particularly persuasive when there are repeated reports of homebirth deaths.

On Mothering dot com there is approximately 1 homebirth death per month and has been for years. National mortality statistics for homebirth midwives are dismal and individual states like Colorado have truly appalling death rates at homebirth. Perhaps most difficult to sweep under the rug are the individual stories of homebirth deaths such as those recounted in The Daily Beast or on personal blogs. As much as homebirth advocates would like to pretend that these deaths don’t happen, they can’t pretend that these stories are not real. At that point, the fallback strategy is to insist that these homebirth deaths don’t count.

Although homebirth advocates have many reasons for ignoring homebirth deaths, some reasons are more popular than others. What follows is a list of the “Top 5 Reasons to Ignore Homebirth Deaths.” Feel free to suggest others that should be added to the list.

Number 5: It was the mother’s fault.

This is always the first reason. We should blame the mother because …

… the baby was breech; there were twins; it was a VBAC. Never mind that homebirth midwives in states like Oregon insist that these women are not high risk. If the baby dies, suddenly risk becomes important.

… the mother ignored the midwife. The story typically does not mention that, but homebirth advocates love to pretend that is what happened and then rhapsodize on the midwife’s professional obligation to attend the patient anyway.

… the mother dared to complain that her baby died. This isn’t the cause of death, but it shows that the mother is a bad person and we don’t need to be upset that her baby died.

Number 4: It was the midwife’s fault.

Surely the midwife must have handled the situation improperly. A “good” homebirth midwife never has a perinatal death, so the fact that the baby died “proves” that a bad midwife was attending in this case. All the other homebirth midwives in the world, with the exception of this midwife, are safe practitioners.

Number 3: This baby would have died in the hospital.

This excuse is almost always rendered in the following fashion: “We don’t really know the details in this case; it’s just as likely that this baby would have died in the hospital.” In other words, it’s basically the baby’s fault and no one could have saved it. There’s never any explanation as to why the hospital would not have been able to save this particular baby. No real explanation is ever needed in order to counsel others to ignore the death.

Number 2: Some babies died in hospitals.

Okay, maybe this baby could have been saved at the hospital, but so what? Some babies die in the hospital, right? Therefore, that proves that giving birth in the hospital is just as dangerous as giving birth at home.

Umm, no it doesn’t. Yes, some babies die in the hospital, but those babies are almost always premature or have congenital anomalies incompatible with life. The issue is not whether some babies die in hospitals, but whether babies die of preventable causes in the hospital.

This also ignores the fact that MORE babies die at home than in the hospital. More dead babies means homebirth is more dangerous. The fact that some babies die in hospitals tells us nothing about the relative safety of homebirth and hospital birth.

And the Number 1 reason why we should ignore homebirth deaths: Babies die.

Homebirth advocates express a surprising amount of fatalism about homebirth deaths. The following comment is representative of this viewpoint:

First of all, Amy, babies (and mothers) die. It’s a fact of life. You will never have 100% survival rate. So what’s acceptable? Knowing that there was nothing that could have been done or that if you had have done something, you may well have ended up with a baby that was so damaged, it would have been better off dead. For others, it’s knowing that it’s God’s Will. You are arguing against religious and personal freedom by saying that we should treat all women the same.

Weitz and Sullivan quote a homebirth midwife in Licensed Lay Midwifery and the Medical Model of Childbirth:

Basically one of the things I object to about the medical profession is their one hundred per cent rule, their unwillingness to accept the fact that sometimes people are just supposed to die or babies are just supposed to die or that there is a place for less than perfect and less than one hundred per cent.

So there you have it, folks. No need to worry about those dead homebirth babies. It was the mother’s fault. Or maybe it was the midwife’s fault. Or maybe it was the baby’s fault. If all else fails, just declare that “babies die.” It’s sad, but “shit happens.” Sure a lot of “shit happens” at homebirths, but that doesn’t mean that homebirth isn’t safe, does it? Does it? Nah … it’s just an unfortunate coincidence.

Heads up, Colorado Legislature!

You will be conducting a sunset review of Colorado’s Midwives Practice Act 2011. According to the Colorado Office of Midwifery Regulation:

…The Sunset process is an opportunity to look critically at the statutes – whether regulation by the Department of Regulatory Agencies is necessary to protect the public health, safety and welfare. In addition, the operation of the agency is reviewed to ensure consistency, efficiency and effectiveness; and evaluate if administrative and statutory changes are necessary to improve the regulation of its practice…

Here’s what you need to know:

The death toll of homebirth in Colorado is enormous and RISING!

Last year I wrote about the horrifying death toll of homebirth in Colorado:

… [T]he perinatal death rate of LICENSED homebirth midwives in Colorado, caring for low risk patients, exceeded the perinatal death rate of 6.4/1000 for the entire state (all races, all gestational ages, all birth weights, 2003-2007)! Homebirth was the most dangerous form of planned birth by far.

Karen Robinson, CPM [President of the Colorado Midwives Association] was in denial:

I don’t believe we have a poor perinatal mortality rate, but if solid data shows we do, then I will be at the forefront of the effort to improve our practices and lower the perinatal mortality rate for homebirth in Colorado.

But as I pointed out in my post:

If she’s going to be at the forefront, then she had better get out there. The just published statistics for the year 2008 are even worse. Last year, licensed Colorado midwives had a perinatal mortality rate at homebirth of 8.6/1000. These numbers are nothing short of horrifying.

Amazingly, the 2009 statistics are far worse. In 2009 Colorado licensed midwives provided care for 799 women. Nine (9) babies died for a homebirth death rate of 11.3/1000! That is nearly DOUBLE the perinatal death rate of 6.3/1000 for the entire state (including all pregnancy complications and premature births).

The data is conveniently broken down by type of death and place of death. For example, there were three intrapartum deaths for an intrapartum death rate of 3.8/1000, more than TEN TIMES HIGHER than the intrapartum death rate commonly experienced in hospitals. There were 4 neonatal deaths for a neonatal death rate of 5/1000. That’s TEN TIMES HIGHER than the national neonatal mortality rate for low risk hospital birth with a CNM. On hundred women were transferred in labor or after delivery for a transfer rate of 12.5%. The neonatal death rate in the transfer group was 50/1000, an appalling neonatal death rate ONE HUNDRED TIMES HIGHER than that expected in a group of low risk women.

What can we learn from these data?

1. Planned homebirth with a licensed midwife in Colorado has a death rate that is extraordinarily high and has risen in every year since statistics were first collected.

2. Colorado homebirth midwives have an intrapartum death rate 10 times higher than expected.

3. Colorado homebirth midwives have a neonatal mortality rate 10 times higher than expected.

4. Colorado homebirth midwives fail to transfer enough patients and fail to transfer them in a timely fashion.

5. One in 20 patients transferred to the hospital by Colorado homebirth midwives ends up with a dead baby.

I recently asked how many dead babies does it take to convince a homebirth advocate of the dangers of homebirth? Evidently, there is no limit to the number of dead babies that Colorado homebirth midwives think is acceptable.

Hopefully the Colorado Legislature is not nearly so irresponsible. The sunset review should conclude by letting Colorado direct entry midwives ride off into the sunset permanently. Like all American direct entry midwives, they are grossly undereducated, grossly undertrained, and, as a consequence, unbelievably dangerous.

I wouldn’t go as far as claiming that the philosophy of natural childbirth is purely quackery, but as science systematically eviscerates their claims, natural childbirth advocates are falling back on the defense mechanisms classically associated with pseudoscience.

This represents a radical departure from recent strategies. Unlike traditional pseudosciences (homeopathy, creationism) which have always denigrated scientific research, in the last decade, natural childbirth advocates have based the validity of their philosophy on the claim that it is supported by science while modern obstetrics is not. Indeed, as I have noted in the past, Lamaze International has titled its blog Science and Sensibility to emphasize the purported scientific basis of natural childbirth.

But it turns out that the central claims of natural childbirth advocates are NOT supported by scientific evidence, and many of their claims are completely undermined by existing scientific evidence. Modern obstetrics, in contrast, has always been, and continues to be based on scientific research. Midwifery theorists have recognized this, and celebrity natural childbirth advocates are becoming aware of this problem. To solve it, they are resorting to the tried and true tactics of pseudoscience.

I wrote yesterday about Amy Romano’s parting shot on Science and Sensibility. She is leaving one special interest group (Lamaze International) to work for a natural childbirth lobbying group (The Childbirth Connection), and I find it fitting that she uses her departure to firmly situate natural childbirth as quackery.

Consider what Romano wrote:

… [W]e all arrive at the point of healthcare decision making with a different constellation of factors that affect our choices. We may have different financial resources, health situations, hopes and plans for the future, tolerance to pain, tolerance to risk, prior experiences, and so on.

In other words, with the exception of practices that cause harm with no counterbalancing benefit at all or benefit with no risk of harm at all, there is no such thing as a good or bad healthcare decision. There’s only such a thing as a good or bad healthcare decision for a certain person. Evidence cannot guide practice without the other piece of the equation – the person to which the evidence is to be applied. (emphasis in the original)

Now compare it to a style of pseudoscience defense described by Boudry and Braekman in the recently published paper Immunizing Strategies and Epistemic Defense Mechanisms as “changing the rules of play”:

By undermining the standards of reasoning employed in a rational debate, one can safeguard one’s position from valid criticism. In many instances of this immunizing strategy, the very attempt at criticism is condemned as fundamentally misguided…

For example, in discussions about alternative medicine one often hears the claim that each person or patient is “radically unique”, thus frustrating any form of systematic knowledge about diseases and treatments. Of course, advocates of unproven medical treatments use this argument as a way to deflect the demand for randomized and double-blind trials to substantiate their therapeutic claims. If each patient is radically unique, there is no point in lumping patients together in one treatment group and statistically comparing them with a control group… The argument is so convenient that it has been borrowed as an immunizing strategy by countless alternative therapists …

Romano follows this description almost exactly. She is clearly attempting to undermine the use of scientific evidence as the standard of reasoning used in rational debate. She directly appeals to the notion that since each person is “radically unique,” there’s no point in basing clinical decisions on scientific evidence. Indeed, Romano is basically saying that scientific evidence is irrelevant, and can and should be ignored when it conflicts with cherished personal beliefs.

I doubt Romano even realizes it, but her post allows me to declare victory. I have been writing for years that natural childbirth has nothing to do with scientific evidence. Natural childbirth philosophy was developed by a eugenicist (Grantly Dick-Read) who lied about the pain of childbirth with the explicit intention of convincing white women of the “better” classes to have more children than “primitive” (read: black) women. It has been perpetuated by people who have disregarded scientific evidence. And now, in 2010, Amy Romano writing under the aegis of Lamaze is trying to provide a justification for explicitly ignoring scientific evidence.

The days of declaring that natural childbirth is based on science are over; they have come to an abrupt end because it has finally penetrated the consciousness of natural childbirth advocates that their claims are not and never were based on science. At this point, natural childbirth is perilously close to becoming nothing more than a form of quackery.

Amy Romano got tired of me making her look like a fool. No, she didn’t stop writing foolish things; she just deleted my latest comment that exposed her writing as foolish, and untrue to boot. Evidently I spoke too soon when I wrote last week:

Henci Goer has banned me: too hard to address my points. The Unnecessarean has banned me: too hard to address my points. Jennifer Block doesn’t let anyone comment on what she writes: good idea since she can’t address anyone’s points. Only the folks at “Science” and Sensibility haven’t banned me. I don’t know why since I have torn apart multiple posts that they have written. I guess that while they may not know much about science, they appear to understand integrity.

They apparently agree that I have torn apart what they have written and they don’t want to let me do it again. Fortunately, I have my own blog on which I can reply.

Amy Romano has discovered that:

I was wrong. Evidence doesn’t hold all of the answers.

In other words, she has caught up to the midwifery theorists who have already found out that the scientific evidence does not support their claims. I wrote about this problem almost a year ago in Midwives have a problem with scientific evidence:

… [M]idwives and childbirth educators like Lamaze have a problem. The scientific evidence often conflicts with their ideology… [Therefore] they’ve tried to justify ignoring scientific evidence.

As midwives Jane Munro and Helen Spilby have documented in The Nature and Use of Evidence in Midwifery, midwives were initially enthusiastic about basing clinical practice on scientific evidence. That’s because they had long told each other that midwifery was “science based” while obstetrics was not…

But (surprise!) it turned out that obstetrics had been based on scientific evidence all along and it was midwifery that ignored the scientific evidence in favor of ideology…

… As Munro and Spilby explain:

‘… [S]ome midwives have not been so enthusiastic [about evidence based practice], viewing the drive to create and implement evidence as a threat to their clinical freedom.’

In other words, cherished ideological beliefs conflict with scientific evidence. Thus began the attack on scientific evidence.

Romano is following that tactic. She writes:

There are many reasons I have come to believe [that scientific evidence doesn’t hold all the answers], but there are two I want to write about today. The first is that the way research is currently funded, conducted, and disseminated, it simply doesn’t address many outcomes that women care about.

Those evil doctors and scientists are concerned with what is safe and what is dangerous, but midwives don’t care about THAT.

The second is that we all arrive at the point of healthcare decision making with a different constellation of factors that affect our choices. We may have different financial resources, health situations, hopes and plans for the future, tolerance to pain, tolerance to risk, prior experiences, and so on.

In other words, with the exception of practices that cause harm with no counterbalancing benefit at all or benefit with no risk of harm at all, there is no such thing as a good or bad healthcare decision. There’s only such a thing as a good or bad healthcare decision for a certain person. Evidence cannot guide practice without the other piece of the equation – the person to which the evidence is to be applied.

So clinical practice SHOULDN’T be guided by scientific evidence, because scientific evidence does not support the central claims of natural childbirth. Better to pretend that scientific evidence cannot tell us about individuals and only they can figure out what is “safe” for them.

In support of this nonsense, Romano offers the typical NCB lie:

In May 2009, Science & Sensibility contributor, Henci Goer, presented the findings of her review of the literature on cesarean surgery and a little-known complication: new onset endometriosis. She wrote:

‘So why is this reasonably common serious adverse effect of cesarean surgery something you have never heard of?…Cesarean wound endometriosis would never turn up in a randomized controlled trial (RCT). Even if the problem made it onto the researchers’ radar, the trial would have to be extremely large and follow-up impractically long to detect it. Where RCTs are considered the only evidence worth having, outcomes that cannot be picked up on by RCTs functionally don’t exist.’

Endometriosis is not a “little-known” complication of C-section. Just a brief search of the internet brought up a paper from 1965 and it had been well described long before then. That same brief search revealed literally hundreds of papers on the topic (I stopped counting at 400). Oh, and those papers were not RCT’s because, contrary to Goer’s assertions, RCT’s are not required in order to recognize a phenomenon.

How can supposedly “educated” women fail to be aware that there are hundreds of papers on the topic extending back many decades? They lack basic knowledge of science, statistics and obstetrics. They actually think that because THEY didn’t know something, it must be unknown.

At least Romano has inadvertently acknowledged what I have been writing all along: scientific evidence does not support the central claims of natural childbirth advocacy. In the world of Lamaze, if the evidence doesn’t support the claim, you have to throw out the evidence, … and then you have to delete it if anyone dares to post it on your blog.