Friday, June 02, 2006

All Natural Cheetos

It seems like people are having difficulty understanding the meaning of the post about marketing.

I am hardly an expert on marketing, but I do know that marketing involves various tactics. The best one is to market based on the true virtues of the product. So, for example, if a laundry detergent is the best at removing grass stains, you can market it as "best at removing grass stains" and that will attract certain buyers.

Of course, not every product has virtues that are worth marketing. So often times marketers resort to other strategies, appealing to instincts and preconceived ideas of potential buyers. Take Cheetos for example. There is absolutely nothing nutritionally redeeming about Cheetos. No one is going to be able to market them as "good for you". So the marketers did the next best thing. Appealing to an inate belief among buyers that "natural" is better, they've now brought out a product called "All Natural Cheetos". Cheetos are just as bad for you as they ever were, but the marketers have blunted this perception by appealing to unconscious beliefs about natural products.

So lets take a look at the the marketing of natural childbirth:

Professor Thompson believes that most people come to the issue of childbirth with the assumption that modern obstetrics has had tremendous success in making childbirth safer for babies and mothers. Therefore, they are not inclined to believe that returning to "natural" childbirth is safer or better. This is a marketing problem and the natural childbirth movement has addressed it with a marketing solution. As Prof. Thompson describes the marketing problem:

[Most people believe that] medicalized births would have never gained a cultural foothold if they were so risk laden and ... the medical profession would not support obstetric practices that place laboring women at risk.
He also describes the marketing solution:

.., the 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..., 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...

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.
In other words, the natural childbirth marketing campaign attempts to discredit obstetrics as a profession by appealing to notions of fairness and to cynicism about motives. They don't say that obstetrics hasn't saved millions of women and infants; that would be ridiculous and people would see through that immediately. Instead they say "Look at those evil obstetricians. Those men drove innocent and highly competent women from the business of delivering babies so they could make all the money themselves. Sure obstetricians have all this great technology, but that exists mainly to trick people. Obstetricians invent and even deliberately create emergencies so they can show their technical skill and pretend that they are heroes."

Notice how they attempt to divert attention from the real issue, whether natural childbirth is safer than the medical model. They enlist conscious and unconscious notions about fairness and greediness instead. It's just like the All Natural Cheetos marketers who are trying to enlist conscious and unconscious notions about "natural" to make you ignore the fact that Cheetos have no intrinsic nutritional value.

Natural childbirth marketing uses two additional tactics:

One of the great virtues of modern medicine, indeed of modern science itself, is that there is a wealth of information and points of view fighting it out in the medical literature and allowing individual doctors and scientists to evaluate data and draw their own conclusions. New data and new points of view are constantly being introduced, forcing doctors to re-evaluate their thinking about medical issues. Dissenting views are allowed, and not supressed. This is a virtue of the medical system, but natural childbirth marketing attempts to turn it into a weakness.

The natural childbirth literature emphasizes this internal dissension in the medical profession and portrays these dissident voices as the enlightened parties who are breaking ranks with an entrenched dogma.
There are always dissident voices in medicine and most of them are wrong, but natural childbirth marketing doesn't attempt to evaluate whether the dissidents are correct. It tries to leverage conscious and unconscious notions that dissidents are "more enlightened" than others.

Similarly, as new knowledge is acquired, medical practice changes.

During the past 50 yr., many obstetric interventions that were once deemed to enhance the safety of birth or to improve postpartum outcomes—shaving ..; mandatory intravenous drips; .., lithotomy position; enemas; ... etc. have all been discarded as ineffective, unnecessary, and in some cases, potentially harmful... The natural childbirth community invokes this historical legacy to argue that many contemporary obstetric interventions are likely to meet a similar fate.
So instead of recognizing the willingness of the medical profession to change as new knowlege becomes available, natural childbirth marketing expresses disgust that doctors were wrong in the past and implies (without evidence) that this means that everything they say and do is likely to be wrong.

The beauty of natural childbirth marketing, like most marketing, is that it is basically unconcerned with the facts about the product. It's all about the perception of the product and the perception of the competing products.

That's why many homebirth advocates are often incapable about making arguments about the actual safety of natural childbirth. They are often stunned (whether they admit it or not) when they are forced to confront the fact that there is no evidence for their beliefs. They have been lulled into making a decision about a safety issue by appeals to their conscious and unconscious beliefs about fairness, greediness, dissidents, power issues between men and women and other irrelevant issues.

The prime example of this is the way homebirth advocates constantly quote medical papers from the 1930's or even the 1800's. They are about as relevant to a discussion of contemporary obstetrical issues as are papers by medieval physicist are to a discussion of Einstein's theory of relativity. It would be laughable except for the fact that they don't seem to realize that they are no longer discussing the facts of childbirth safety, but are instead using marketing tactics to promote a product that otherwise could not compete in the marketplace of ideas.

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42 Old Comments:

part of Amy's 4th post on this blog---

""However, anesthesia is only about 150 years old. Over 99.9% of women who have ever existed have had natural childbirth. Right now, at this moment, virtually all the laboring women in a host of countries and on a variety of continents are having natural childbirth. There is simply no other alternative."

you have been using history to support your points on this blog and others....
--------------------
when and why is history useful?
not just as a marketing ploy....
with 99.9% of all women giving birth "naturally" why participate in your little drug experiment?
sounds like some sort of successful add campaign to me-- who's selling the Cheetos anyway..

By Anonymous Anonymous, at 5:40 PM  

I think this is a interesting and well-made point.

Amy, I'm curious: Do you see, as I do, the parallels to some other practices which border with and occasoinally overlap modern medicine? The "marketing" techniques for many of these other areas mirror closely the tactics which you have described for midwifery.

Without even naming them, I am sure you know which I mean.

By Blogger sailorman, at 5:53 PM  

Sailorman:

"Do you see, as I do, the parallels to some other practices which border with and occasoinally overlap modern medicine?"

Oh, yes. These marketing techniques are common to all forms of "alternative" health. There is an ongoing attempt to appeal to people's conscious and unconscious perceptions and a strenuous effort to divert attention away from whether "alternative" health methods actually work (since none of them do).

I will say, though, that both direct entry midwifery and alternative health practitioners capitalize on a serious deficiency of doctors. There is no doubt that many doctors are not respectful of patients, are dismissive of any symptoms that they can't treat, and do not spend enough time with patients. Alternative health practitioners do offer these very real benefits, although their treatments are useless and occasionally criminally fraudulent.

By Blogger Amy Tuteur, MD, at 8:03 PM  

Amy, you wrote Notice how they attempt to divert attention from the real issue, whether natural childbirth is safer than the medical model

Are you arguing against the marketing of natural birth, or out of hospital birth? It amuses me that you think 'natural birth' is the opposite of the medical model. Says a lot. I think you must have meant midwifery model?

I'm also interested as to where you (or Prof. Thompson) think this this marketing is occuring? I really do wish there was marketing for OOH birth midwifery, but unfortunately I don't think we have any yet. If you mean individual women sharing their own home birth experiences, isn't marketing a bit of a verbal stretch? Marketing would seem to me an organized professional endeavor, which sadly, we don't yet have.

By Anonymous maribeth, CNM, at 9:12 PM  

I would not have considered that a mere 1% of the market would have been thought of as successful marketing compared to the 95+% plus of healthy women that we have not yet been able to reach.

Telling, they way the things are interpreted here!

I read a news report that New Mexico Midwives now outnumber OBs, which of course is a step in the right direction.

Perhaps this an issue at hand?

By Anonymous seriously, at 10:08 PM  

I see by the responses this is not suppose to be about natural birth- as presented in the diatribe it is about your opinion that natural birth is quackery..... useless and unneeded-
do you/have you given your patients a disclaimer about your beliefs and bias against "natural birth" no matter the setting?

By Anonymous Anonymous, at 10:28 PM  

I don't see any parellels between Cheetos and childbirth, sorry.
I think you misrepresented Thompson's article a bit as well, adding your own spin to it that doesn't exist in the article itself. But that's classic Amy.

I am not sure what point you're trying to get at, except perhaps that you feel marketing should only be done by people/products you espouse?

Why is it that the marketing of natural childbirth (1% of the population) gets you in such a tither? Odd.

I wish you would have replied to the requests under your marketing post asking you where the false information in the 'campaign' is exactly.

By Anonymous stumped, at 11:47 PM  

"I read a news report that New Mexico Midwives now outnumber OBs, which of course is a step in the right direction."

I'm not sure if the NM midwives outnumber OBs (possible), but I do know that Taos County, NM has the highest OOH birth rate in the country. It is at least 25% and may be as high as 33% now. The midwives in Taos County serve an 85% Medicaid population and many unmarried mothers. Medicaid actually pays for home birth in NM, both with CNMs and CPMs.

Apparantly the OBs and midwives have a good working relationship as well. The midwives actually train the OB residents in labor and delivery. (I don't know how unique this is because I've been told that this is the case at the University hospital in my midwestern town as well.)

By Blogger Mama Liberty, at 9:23 AM  

People are stilling having difficulty figuring out my point. Here's the "money quote" :

"That's why many homebirth advocates are often incapable about making arguments about the actual safety of natural childbirth. They are often stunned ... [by] the fact that there is no evidence for their beliefs. They have been lulled into making a decision about a safety issue by appeals to their conscious and unconscious beliefs about fairness, greediness, dissidents, power issues between men and women and other irrelevant issues."

In other words, many homebirth advocates don't have any knowledge of the safety issues, and often don't know enough about science and statistics to evaluate the issues. They have made their decision based on appeals to conscious or unconscious beliefs. These beliefs are actually irrelevant to the issue of whether homebirth is safe, just like the fact that Cheetos are "all natural" is irrelevant to whether or not it is good for you.

I have been consistently puzzled by the homebirth advocates' habit of quoting from papers that are 100 years out of date as if that proved something. I thought it was a sign that some homebirth advocates are so unsophisticated that they actually believed that someone could be swayed by information that was hopelessly out of date.

Now, however, I understand the motivation. They had swallowed the marketing attempt to divert attention from the issue of safety to the issue of whether doctors were mean to midwives. Since their outrage against doctors' treatment of midwives had convinced them that midwives were unfairly persecuted, they thought it might convince me.

By Blogger Amy Tuteur, MD, at 10:36 AM  

This comment has been removed by a blog administrator.

By Blogger Mama Liberty, at 10:50 AM  

"I have been consistently puzzled by the homebirth advocates' habit of quoting from papers that are 100 years out of date as if that proved something."

Well in the context of this particular debate when posters have quoted from historical primary source documents it has been to counter your lies and misprepresentation of history. If you are willing to distort historical fact, then you are not a trustworthy source for accurate information, period.

"I thought it was a sign that some homebirth advocates are so unsophisticated that they actually believed that someone could be swayed by information that was hopelessly out of date."

Can we talk a little more about the general higher educational attainment of homebirth mothers? How does that square with your portrayal of "homebirth advocates" as a bunch of blithering idiots incapable of adding two plus two?

By Blogger Mama Liberty, at 11:29 AM  

Amy says; 'In other words, many homebirth advocates don't have any knowledge of the safety issues, and often don't know enough about science and statistics to evaluate the issues.'

but I thought one of your arguements for comparing control groups to homebirthers are that homebirthers are highly educated and white. Both can't be true. Pick one and stick with it. You're flip flopping.

By Anonymous Anonymous, at 12:48 PM  

Highly educated doesn't mean one can think logically. It means one can somehow get through college and earn a degree in any subject.

By Anonymous joanna, at 3:56 PM  

"It means one can somehow get through college and earn a degree in any subject."

Like a medical degree? Don't you find it just a teeny bit interesting that those with a higher level of education are more likely to choose a homebirth?

By Blogger Mama Liberty, at 4:32 PM  

"I have been consistently puzzled by the homebirth advocates' habit of quoting from papers that are 100 years out of date as if that proved something."

I commented on this a couple of posts up, but I have another thought about this...

Do you realize that one of the most effective arguments the medical lobby makes to legislatures is that birth moved from the home to the hospital because it was safer? So really, I think when you come across many of these historical discussions, it is an effort to set the record straight, not to prove anything about the safety of home birth today.

In 2005, my jaw just about dropped when a medical doctor from our state board of health whipped out some statistics from the 1920's in order to testify against allowing midwives to practice in our state in the twenty first century! You could almost see the wheels of the senators turning... "well, duh, she's right... obstetricians took over because hospitals were safer and they had better skills. Of course we shouldn't go back! Why would women want midwives anyway?" End of story. No further look at what the historical record ACTUALLY shows.

No, this historical discussion actually eminates from the the medical camp because it has been a very effective tool in enabling them to continue wielding the power of their monopoly.

On the other hand, some of the discussion happens because it is just plain interesting. There is no lack of wisdom in trying to understand history accurately.

By Blogger Mama Liberty, at 4:46 PM  

The issue here is straight forward, but no one seems willing to directly address it.

Are homebirth advocates truly knowledgeable about the safety issues (exceedingly doubtful since approximately nobody seems to have read the actual papers) or are they swayed by appeals to conscious and unconscious ideas about tangential issues?

Based on the comments, it seems like the tangential issues are winning out over the safety data. For example, the issue of out of date papers is IRRELEVANT to whether or not homebirth is safe. Yet, many are still arguing this point as if it matters. It only matters if you are trying to divert attention away from the safety data and convince people that homebirth is a good idea because doctors were mean to midwives.

By Blogger Amy Tuteur, MD, at 5:32 PM  

For any subject I meant even "gut" majors counted the same as people who took demanding courses such as calculus or whatever.
Gut majors vary by school, of course. At mine, they were phys ed and home economics.
No, it doesn't really interest me that of the few who homebirth, many have gone to college. A LOT of people go to college these days. As a graduate student, I taught at a major research university and plenty of those kids were dumb as posts.

By Anonymous Joanna, at 6:56 PM  

and maybe the core issues are part and parcel with what has been done in the past as much as what is done today. Such as physician supported and guarded laws that keep midwifery at less than standard of care-- in some states midwives are legal but not allowed to carry Oxygen, pitocin, methergin, IVs , GBS prophylaxis, suture materials so there can be a delay in care --- in ambulances although they carry oxygen and IVs often they do not have a neonatal mask- so you can carry a bag and mask for mom and baby but not oxygen -- and pitocin is an optional item in an ambulance.
the studies that are a collection of CPM stats would reflect the different allowed practices-- of course you could have some midwives risking their freedom to provide standard of care to protect a mom or baby.
most likely someone should sue the states that keep appropriate standard of care out of the hands of midwives-- they are risking mother and baby lives.
on another front
in the same way you can be dismissive of studies even done by anesthesiologist and others about neonatal effects of epidurals because you have a bias , experience, or that you can find a confounder that solves the makes it maybe not true..
what about the recent studies on delayed cord clamping?
Now I also want talk about the words you choose or pick for your lectures/rants. Natural birth and home birth are not the same thing. Home birth is a place- a setting just like the word hospital or birth center or back seat of a cab . It is in the nature of women to give birth, just like chickens lay eggs or men have sperm. But "natural birth" in america is most likely defined as unmedicated birth- (unmedicated in the sense of no anesthesia drugs, and for some it means no inductions either) -- and that is why so many women have birth plans because they each define the birth they want and the meaning of things like "natural".
so to guess at potential trends or dangers when I look at the studies -- I don't see the same things as you-- you blow off the hospital related cord prolapse as a pre-existing problem maybe yes maybe no-- since ROM can and does cause cord prolapse in hospitals with a 50-50 chance of no-damage even with a woman intends to birth there at the onset of labor. And the undetected till labor vasa-previa very low stats on that even in the hospital. Sub-gleal hematoma-- what can I say don't have a vacuum extraction -quoting one article on the subject-"All except three of the infants admitted with SGH had instrumental deliveries (31 of 34; 91.2%): 21 vacuum, eight vacuum followed by forceps, two forceps)." --- when might the use of a vacuum extractor be helpful- very remote places, 3rd world countries - during natural disasters .
----
congenital abnormalities incompatible with life-- do think I can fix or do anything about this one.

By Anonymous Anonymous, at 8:51 PM  

"Are homebirth advocates truly knowledgeable about the safety issues (exceedingly doubtful since approximately nobody seems to have read the actual papers) or are they swayed by appeals to conscious and unconscious ideas about tangential issues?"

Which is it, Amy? In this post you claim we are incapable of recognizing risk and in your most recent post you point out how many of us transfer, presumably due to some identification of a risk factor before or during labor.

By Blogger Mama Liberty, at 9:17 AM  

There have been a number of snappy replies, but no one has actually addressed the issue:

Did you read the literature about safety before you made a decision about homebirth? Or did you make your decision based on an appeal to conscious and unconsious feelings about tangential (and generally irrelevant) issues.

No one has yet come forward to say, "yes, I read the safety literature and that's how I made my decision". That seems to confirm the notion that women made their decisions for other reasons, and that the "marketing" campaign for natural childbirth is very effective.

The entire thread appears to support this contention. Virtually every post is an attempt to discuss tangential and usually irrelevant issues.

By Blogger Amy Tuteur, MD, at 10:53 AM  

"Did you read the literature about safety before you made a decision about homebirth?"

Yes, I read literature about safety before I made a decision about homebirth. I also read a good deal of literature and discussion about safety of common obstetrical practices and decided that for ME home birth would be safer in terms of my baby's health and my health. At the time I had two other children who needed a mother, so yes, I considered my own risks as well as possible risks to my new baby.

One thing I've noticed that you haven't addressed is the value of experience in decision making. I did not make my decisions merely based on literature, but on experience as well. I had numerous negative experiences with obstetricians which lead me to consider and investigate the option of midwifery and home birth.

By Blogger Mama Liberty, at 11:46 AM  

Mama,

This has NOTHING to do with you, or whether YOUR personal decision was good. I am trying to make a general point so please don't take this personally.



However, I'd like to point out that "personal experience" is, often, wrong. It is used as justification for prejudice and bad decisions on a daily basis.

You said
"One thing I've noticed that you haven't addressed is the value of experience in decision making. I did not make my decisions merely based on literature, but on experience as well. I had numerous negative experiences with obstetricians which lead me to consider and investigate the option of midwifery and home birth."

The truth is is that the "value of experience in decision making" is not so great. It's even less valuable when you're trying to make an either/or decision between things which are relatively close in absolute worth.

Were the OBs you saw "standard?" Were the midwives you saw "standard?" Chances are that you didn't see enough of them to be able to make a general statement with any certainty about either, though you thought (like many people) that you did.

By Blogger sailorman, at 12:44 PM  

yes Amy I was a midwife before I had my home births..... and I have read the issues-- and also what the gaps are.

By Anonymous Anonymous, at 1:04 PM  

I have read the literature, on saftey of common procedures of homebirth and hospital. I will have a home birth next time I have a baby. Unless medical indications show that it is not safe for me to have an OOH birth.

This doesn't really answer your question though, because how we each weigh individual risks to ourselves is how we come to the decision. What medical indication will put the risks too high for me, and too high for you, might be two very different things.

The way doctors weigh risks to a woman may not be the way she'll weigh them for herself and her family.

Her experience plays a part of this. I don't know a real person who fits this sinerio, but what if a woman underwent a c-section before, and would rather die than do it again? For her, avoidance of the c-section would be paramount.

I personally looked at the literature, and decided that the very small chance of a 'poor outcome' OOH was worth betting on, rather than the rather larger chance of injury to myself in hospital added to the very small chance of a poor outcome in hosptial.

By Anonymous Anonymous, at 1:21 PM  

Chiming in, yes, I read the literature before becoming involved in homebirth. I disagree that homebirth proponents have not ever read the evidence, which you're holding as a basic truism. I reiterate that many of us disagree that the evidence shows homebirth to be less safe than hospital birth. I do realize you really really really want us to concede that point, but we don't think it's correct.

By Anonymous maribeth, CNM, at 1:33 PM  

Sailorman wrote---
The truth is is that the "value of experience in decision making" is not so great. It's even less valuable when you're trying to make an either/or decision between things which are relatively close in absolute worth.
--------------------------------
so sailorman the your point being what? medical doctors do many many things that are not studied, and are based on experience- look a Amy's dismissal of studies done about breastfeeding effects and epidurals-- it will probably be another 20 years before the medical profession catches up with mistakes they are making now- because there has to be enough new doctors reading the research and believing it and taking over practice--
an excellent example would be the routine use of episiotomy and how it has dropped - when was the big push from consumers to study and change practice -- in the late 60's-80's. But there is evidence as far back as the 1920-30's that episiotmies were not necessary and in that time period killing women because it created a place for infection. So no I am not trying to only bring up history but to also say - evidence if there is any, experience is how most decisions get made- in and out of the medical field.
also Amy has very carefully created this discussion titled "home birth" but refuses to even talk about MATERNAL MORTALITY and MORBIDITYt--- the fact that the mother has a much higher risk of being seriously injured or killed in hospital birth--- and that needs to be weighed with what has happened with neonatal morbidity and mortality -- and if you control out high risk births from home birth studies( breeches and twins, vacuum extractor births) and inevitable deaths of congenital anomalies incompatible with life-- where is the most risky place to give birth for all concerned?


there are more things in a study than just the bottom line of nunmbers- it is also in the details--
other risks--
like cord prolapse - certain kinds of routine care done in hospitals - see the studies posted earlier-- can increase the risk of a cord prolapse so the increase risk is 47% [probably higher because I think that putting a woman to bed in labor increases risk but now do you think that this is ever going to be studied?] - and out of the cord prolapse cases they can save 50%- which ones, and do they have any long term damage- yes there is evidence that even in the ones that are saved- the birth has to be facilitated within 20 minutes or there can be neuro insult. There are additional confounders to this including time of day the birth takes place- if you give birth in the day time better chance your child will be saved- at night time 50% more likely to not make it-- because of hospital schedules--- and this rate is not just for cord prolapse but for all.
In the BMJ homebirth study- how many cord prolapses 6 transfers with 1 death( the prolapse that happened in the hospital) , some studies of hospital birth say 3/1000 cord prolapse - the BMJ homebirth rate was 1.1/1000 cord prolapse .

By Anonymous Anonymous, at 2:01 PM  

" maribeth, CNM said...
I read the literature before becoming involved in homebirth. I disagree that homebirth proponents have not ever read the evidence, which you're holding as a basic truism."

Well, a lot of people on the various threads started out by citing papers, for example. It didn't take long to realize that almost none of them had really read the papers. In fact, an embarassingly large proportion seem to have read only the abstract of many of the papers they cite. Some others may have "read" the papers, the same way I "read" parts of the Inferno as a young child because I thought it looked cool. But in the context of a scientific paper reading means something different, and includes "evaluating" and "analyzing" in addition to "memorizing."

If you can discuss the conclusions, you have "sort of read" the paper. If you can discuss them in the context of the subject, and ALSO discuss the data underlying the conclusions, along with any problems, and the author's explanation for the problems, and offer your own opinions on the data, then you've read the paper.

So it DOES seem to be the case that almost none of the home birth advocates who post have read these papers in detail before developing an opinion. If you did so, you are a rare, and admirable, exception.

By Blogger sailorman, at 2:18 PM  

how much do you know about evaluating the subject Sailorman? -- I have read the papers-- and far more than that-

By Anonymous Anonymous, at 2:48 PM  

"However, I'd like to point out that "personal experience" is, often, wrong. It is used as justification for prejudice and bad decisions on a daily basis."

I completely agree Sailorman... but I have seen this in action on the part of obstetricians. I think it is routine operating procedure (excuse the pun) for members of any profession to rely on their experience in decision making, which is why it is so hard to change the status quo when new evidence comes along. I personally double check anything that is told to me... either from an OB, any other doctor, or even my midwife.

I didn't say that I made my decision completely based on experience, but that my experience led me to consider the alternative. And actually Sailorman, I have had experience with many obstetricians during the years I worked with breastfeeding mothers.

And regarding your other post about whether or not advocates have read the papers... I don't think a woman has to have read a bevy of research papers in order to be qualified to make decisions for herself and her baby. I have read many papers, but I have also just read many interesting abstracts. I know my limitations (both intellectual and time) and decide who I will trust in addition to my own consideration of the evidence. I personally place more trust in the American Public Health Association than ACOG in homebirth matters because I see ACOG as essentially a trade union. They have a more vested interest in protecting the status quo than does the APHA. No, that is not a conspiracy theory... it is common sense based on an understanding of how markets work.

By Blogger Mama Liberty, at 2:51 PM  

Thank you Mama, great points.

Sailorman wrote If you did so, you are a rare, and admirable, exception

Thank you. In fact, we have all the studies (including the awful Pang study, with rebuttals) laminated for all of our clients to review, so they can make the best choice for themselves. Of course, most come to us already informed. This is why your and Amy's assertion of lack of truly informed choice by homebirthers rings hollow.

By Anonymous maribeth, CNM, at 3:15 PM  

I have to say that while I've been well-read, I haven't been well-studied on the topic of homebirth until this forum began.

And, after reviewing the studies themselves (not just the abstracts) and considering all points, I've changed my stance.

I've decided I'm going to have a home birth with my next baby.

By Anonymous Anonymous, at 3:43 PM  

" maribeth, CNM said...
...we have all the studies (including the awful Pang study, with rebuttals) laminated for all of our clients to review, so they can make the best choice for themselves. Of course, most come to us already informed."

Really? That is great!

But of course now I'm even more curious.... what rebuttals to the Pang study do you have? Do you also post rebuttals to the other studies? I mean, the Pang study has (disclosed) problems but many of the other studies have similarly bad (undisclosed) problems and I don't see many people referring to them as "awful."

I ask because to my eyes, the Pang study is, unlike many of the other studies, extremely upfront about its problems within the body of the study. The other ones, of which the Farm is a commonly cited example, tend not to disclose their problems as honestly.

So if you really want informed clients, I assume you post rebuttals to those too...? If not, that seems biased.

In either case, I think that providing clients with the actual studies relevant to their decision is a commendable step. Hopefully they read them before they make a decision.

Does this mean my comments "ring hollow?" I don't know. Are you disagreeing with what i said regarding the enormous number of people who didn't/don't read the papers, often claiming they did?

-----------------
Mama:

I did a cursory look at the APHA website. As I said before, I do not believe that public health is best suited (or even WELL suited ) to answering specific medical questions like the one we are discussing.

Public health involves politics.

Public health answers questions like "is home birth a good thing" and "do midwives help mothers" and "is midwifery a good use of public funds" and the like. Public health does NOT generally answer specific questions like "is the neonatal death rate for white full term nonsmoking low-risk factor vertex presentation mothers significantly different when they deliver at home versus in the hospital."

Public health addrsses things like "spcial justice" and "social capital" and "community building" and WEIGHS ALL THOSE in making a final determination regarding its recommendations.

So long as there are MORE factors in the public health decision than the one we are discussing (and I am sure you agree that there are) the public health "verdict" IS NOT determinative.

There are many situations in which a small difference in neonatal mortality among a small group of the population would take a back seat to other public health factors. Why is that so surprising to you?

Public. Health. Does. Not. Count.

However you shouldn't need it anyway. After all, there are all those papers, and all that data which we keep discussing. If everyone would stop changing the subject to the APHA then perhaps we could discuss the data.

I understand why you don't want to to that, though. Not many people seem able to dscuss the data because it's detailed, and requires semiadvanced statistics, and is harder to randomly argue about.

By Blogger sailorman, at 4:22 PM  

"Public health does NOT generally answer specific questions like "is the neonatal death rate for white full term nonsmoking low-risk factor vertex presentation mothers significantly different when they deliver at home versus in the hospital."

Oh please, Sailorman, you know that this discussion has turned into a much broader discussion than that very specific point. As far as more specific discussion of the statistics, we only get to discuss the statistics Amy wants to discuss. I would like to start discussing other things like maternal mortality. But we can't discuss that because then we're *selfish*, caring more about ourselves than our babies. I'm somewhat suspicious of the motives of this blog, truth be told.

By Blogger Mama Liberty, at 4:32 PM  

Mama Liberty:

"I personally place more trust in the American Public Health Association"

That fine. The APHA recommends vaccination. Just because the APHA recommends it doesn't mean that some children aren't going to suffer serious complications from vaccination. The APHA recommends it because on balance, it believes that public health is served by it. It makes no claims as to whether a specific individual is going to benefit from it.

Similarly, the APHA believes that the public will benefit from homebirth. It says nothing about whether a specific baby is going to do do well or poorly if it is born at home.

Currently, we are not discussing the public health implications of homebirth, we are discussing specific risks and benefits. On this point, the APHA is silent.

By Blogger Amy Tuteur, MD, at 5:23 PM  

"Currently, we are not discussing the public health implications of homebirth, we are discussing specific risks and benefits. On this point, the APHA is silent."

Do you really think that if we were seeing a significant (your word) number of babies die at home who would have lived in a hospital that this WOULDN'T be a public health concern? I'm sorry, you have really lost me here.

Your vaccination argument makes no sense. If, on balance, more babies will die at home with midwives than in a hospital with obstetricians, how would that be in the public's best interest? You haven't proven whether or not a specific baby will do well or poorly at home, either. You can't. There are too many variables, many of them poorly understood.

Bottom line is that it is up to the mother to decide which risks she and her baby will take. It is not up to the midwife and it is certainly not up to the obstetrician.

I am growing very weary.

By Blogger Mama Liberty, at 5:36 PM  

Responding to Sailorman's post feels like something I did at the very beginning of this blog. (FYI, where ARE the rebuttals to the other studies?).

I think the past few posts really shows how the discussion has come full circle to the same brick wall. Perhaps we are at an impasse?

By Anonymous maribeth, CNM, at 5:58 PM  

Mama Liberty said...
I am growing very weary.

Join the club. I will try to be polite, though.

Oh please, Sailorman, you know that this discussion has turned into a much broader discussion than that very specific point.

Yes, isn't that unfortunate? Don't you see it as a strike against you? The fact that many people here seem unable to separate and discuss a specific and limited issue is tno a compliment.

I mean, it would be one thing if people actually ASNWERED and agreed on the specific point. THEN you could have a productive discussion about another point. You could even build on the initial discussion. We can't do that here, because the home birth folks (you among them) won't let us.

As far as more specific discussion of the statistics, we only get to discuss the statistics Amy wants to discuss.

Well, we get to discuss the statistics that are relevant to the limited question she is trying to discuss. Nobody wants to talk about the limited question, apparently because:
1) They are worried they would lose, and/or
2) They don't understand the argument, and/or
3) They are not capable of balancing the apparent contradiction that something is bad in one way, and good in another way.

I mean, do you realize how often people start posting things which are not relevant to the questions Amy asks?

Do you realize how some people think that the limited issue of neonatal mortality is/should be determinative on whether home birth is acceptable?

I would like to start discussing other things like maternal mortality. But we can't discuss that because then we're *selfish*, caring more about ourselves than our babies.

No, no. Making a decision based solely on the mother's health and personal choices is entirely fine. The selfish part is the pretense that certain things are false. You are joining the "Misquote Amy Club" here.

I'm somewhat suspicious of the motives of this blog, truth be told.

I cannot comment on this and stay even vaguely polite, so I'll refrain.

Do you really think that if we were seeing a significant (your word) number of babies die at home who would have lived in a hospital that this WOULDN'T be a public health concern?

I have absolutely no idea at all. But it's a random question, which misstates (here we go again...) what Amy just said. We don't know. You don't, either, so stop "assuming" you're right.

But yes, I'll explain this again: it is perfectly possible that overall, the difference in deaths is not at the top of the Public Health priority list.

If, on balance, more babies will die at home with midwives than in a hospital with obstetricians, how would that be in the public's best interest?

I do not KNOW if it would be in the public's best interest. I have explained how it COULD be twice, I think. Here, I'll do it again:

Public health looks at overall benefit. Say that home births are 1/1000 higher death rate. Say that using home births means people save $2000 each, which results in a vast decrease of malnutrition, which lowers the death rate by 2/1000. Surrise! Home birth "wins" the public health war even though it is less safe than hospital birth. This is one of an infinite number of possibilities with the same result.

You haven't proven whether or not a specific baby will do well or poorly at home, either.

What on earth does that have to do with anything? [impolite addendum deleted]

Bottom line is that it is up to the mother to decide which risks she and her baby will take. It is not up to the midwife and it is certainly not up to the obstetrician.

Bottom line is that is is up to the midwife not to lie about risk, so that the mother can make her own choice.

By Blogger sailorman, at 6:14 PM  

One thing that I have noticed is that no one really wants to discuss anything unless all the homebirthers and advocates are saying "oh, you have made me see the light and I completely agree with you." Without a statement like that then the homebirthers are told that they just aren't smart enough to carry on a conversation or make decisions. I believe that we have run complete circle and run into the brick wall as well.

By Anonymous Anonymous, at 8:01 PM  

The title of the blog is Homebirth Debate, not Debate on the Rate of Neonatal Homebirth Mortality Only. Of COURSE various related issues are going to come up, and that's not a strike against anyone. You and Amy really should have titled the blog correctly if that was your only intended goal.

And stop pretending as if we threw up our hands in misunderstanding and covered our ears in denial over that subject. Issues of difference were raised, and you could not convince me, for one, that your interpretation of congenital anomalies was correct. You made too many assumptions there, and without those numbers I did not find your argument convincing. I also have said, from the beginning, that I'm not advocating for homebirth of twins or breeches. Excluding those numbers too, my research confirms that homebirth is safer for healthy low-risk women.

I mean, it would be one thing if people actually ASNWERED and agreed on the specific point

As you know, that very point has been my loudest criticism against Amy. Many people have tried to walk step by step through an arguement but have been ignored, making "debate" impossible.

The format is unfair. The blog should be hosted by an impartial host. Today a post of mine was deleted for no reason: it was not personal, it was relevant, I wasn't straining to contain swear words (ahem, sailorman). Amy just did not want it heard. The simple move of including "post removed by author" would show exactly how often this has occured, but even that curteousy isn't included. So I for one am signing out (again).

By Anonymous maribeth, CNM, at 9:48 PM  

this can't be a true debate when posts are deleted by a person invested in the outcome of the debate.

By Anonymous Anonymous, at 12:40 AM  

To be entirely honest, I have no idea what anyone is talking about re deleted posts. I am not running the blog, nor do I know what Amy is doing.

However, EVERY blog deletes posts occasionally. And nobody who runs a blog deletes their own posts (duh)

Given the number (huge) and percentage (huge) of posts here by home birth advocates, it's unsurprising that if a couple of posts got deleted they were in that group. I mean, can you seriously claim that the point of view is not represented?


BTW, if a commenter deletes their OWN post, to my knowledge that shows up. FOLLOWING this post, I will post, and then delete, so y'all can see what it looks like on your screen.

By Blogger sailorman, at 9:15 AM  

This comment has been removed by a blog administrator.

By Blogger sailorman, at 9:15 AM