Thursday, June 01, 2006

Myths and Lies

Homebirth advocacy is based in large part on myths and lies. We have already done some exploration of the major myth, that birth is inherently safe because it is natural. We have seen that there were astounding rates of neonatal and maternal death before the advent of modern obstetrics and those astounding rates of death unfortunately still occur in places where modern obstetrics is not available.

The most important lie/untruth is, of course, that studies show that homebirth is as safe as hospital birth. We have been exploring that in depth as well. Another lie about obstetrics is this: Sure, the neonatal death rate dropped by 90% over the course of the last century and the maternal death rate dropped by over 99% during the same time period, but that's because of an amazing coincidence, the rise of public health.

In their desperation to deny obstetricians credit for their achievements, homebirth advocates have committed one of their cardinal mistakes yet again; they are insisting that because public health advances took place at the same time (and are therefore correlated), they must have caused the improvements in neonatal and maternal mortality. Of course, they don't explain how they know the credit goes to public health since the advances in obstetrics took place at the same time. An exploration of the scientific EVIDENCE, however, shows that modern obstetrics can take the credit.

Before we look at the evidence, I have two preliminary comments. First, this lie speaks directly to the unreasoning hostility of homebirth advocates to modern obstetrics. They are so desperate to deny obstetrics credit for its accomplishments, that they willingly ascribed them to other people. I'm not sure that they noticed, but those other people are doctors, too. Doctors discovered the germ theory of disease, antisepsis, water treatment and other aspects of public health. It certainly was not midwives.

Second, obstetricians are happy to share the credit with other doctors, like anesthesiologists and especially neonatalogists. Modern obstetrics is practiced within the context of modern medicine. Obstetricians are proud and grateful to practice in concert with other doctors to deliver the safest possible care.

Now, let's look at the evidence. Public health measures have had their greatest impact in the area of infectious disease. Antisepsis, water treatment and other measures are specifically designed to prevent the spread of infectious disease. So for public health measures to be responsible for the dramatic drop in neonatal and maternal mortality, the original causes for those deaths would have to be infectious diseases. So what were the primary causes of neonatal and maternal mortality before both measures began to drop precipitously?

In the early decades of the 1900's the primary causes of neonatal mortality (birth to 28 days of life) were prematurity 48%, birth injuries 15% and congenital anomalies 10%. None of these have an infectious basis. In contrast, the primary causes of post-neonatal mortality (after 28 days of age) were chest infections 33%, gastro-intestinal infections 18%, congenital anomalies 6%. Right away we can see that none of the primary causes of neonatal mortality were infectious, so public health measures could not have affected them.

In fact, according to Loudon in On Maternal and Infant Mortality 1900-1960:

In most Western countries infant mortality declined more or less steadily from the late nineteenth century (Sweden and the Netherlands) or the early twentieth (Britain). Most of the decline took place in post-neonatal mortality and is generally attributed to improvements in standards of living in general and nutrition in particular. Neonatal rates declined less steeply, and if neonatal deaths were split into early and late, the early neonatal death rates fell more slowly than the late. As a result of these different gradients, the proportion of the neonatal component of infant mortality, and of the early neonatal component of neonatal mortality, steadily increased.
So, instead of decreasing in response to public health measures, neonatal mortality became an ever larger component of infant mortality as post-neonatal deaths rates from infectious disease began to fall.

Now let's look at maternal mortality. In the early 1920's the maternal mortality rate in the US was 680/100,000. The rate was similar in England and Wales. The most common causes of maternal death (England and Wales) in the early decades of the 1900's were puerperal sepsis 33%, eclampsia with seizures 18% and hemorrhage 7.5%.

Sepsis does have an infectious cause, so if public health measures were responsible for its decline, we should see a slow and steady drop as public health measures spread throughout the country. That's not what we find, however. Maternal mortality does not begin to fall until the late 1930's when both antibiotics and blood banking were introduced. There is no evidence that public health measures had any impact on the maternal mortality rate.

In summary: the primary causes of neonatal mortality have never been infectious and public health measures did not contribute very much (if anything) to the decline of neonatal mortality. The decline in neonatal mortality must be attributed to better neonatology and obstetrical care. Maternal mortality does include a large component of infection, but this did not respond to public health measures and was only controlled by antibiotics. Dramatic declines in maternal mortality from eclampsia and hemorrhage are attributed to obstetrical management and the advent of blood banking.

Hopefully, this detailed explanation will put to rest the homebirth advocacy lie that the precipitous declines in neonatal and maternal death over the last century were caused by improved public health measures.

28 Old Comments:

Forgive me for seeming obtuse, but...

What bloody difference does it make who was or was not responsible for an increase in maternal or fetal health THEN? How is that relevant to whether or not a home birth is less safe than a hospital birth NOW?

I mean, this entire thing seems like a really random argument.

Did medicine make mistakes in the past? Yup--tons of them (bleeding, anyone?).

Does that really affect whether the CURRENT medical practice is mistaken? No, not really: the standards are different, the dissemination of information is different, and the collection of data is VERY different from how it was.

Did midwives make mistakes in the past? Yup, I'm sure they did as well. Though to be honest (and this may surprise some people here) I really couldn't care less either way. It has NO effect on my perception of whether what a midwife does NOW is the right thing or not.

Not to mention the whole "selective perception" problem. If all you're looking for is problems, guess what you find? Problems. Both sides can cherrypick the historical data, drink beer, bitch, and get nothing at all accoplished by doing so.

Dr. Amy, I understand why you're posting this. You've gotten a lot of flak on this subject, and the issue often gets side tracked into this area.

But this is really because the people who bring it up don't seem to understand that it doesn't matter. We used to think bleeding was good for your health. We also used to think the universe revoved around the Earth. What possible relevance do either of those facts have to whether you believe scientists regarding our solar system NOW, or regarding the need for transfusions?

All this represents is people who don't (or can't) understand the real issues, so they try to reach a conclusion which fits within the limit of their understanding. But by doing so, they often reach the wrong conclusion.

By Blogger sailorman, at 9:55 AM  

I don't understand the whole public health measure argument....why does that matter at all? And antibiotics could be considered a public health measure, as they stop the spread of disease.

According to the CDC, prematurity, low birth weight, and maternal complications of pregnancy are still the top causes of neonatal death (at least they were in 2002). Home birth is not really a factor in deaths from prematurity or low birth weight (but good prenatal care might help), and mothers with pregnancy complications are probably going to wind up with hospital births anyway.

And if you're going to decry homebirth advocates for claiming that correlation proves causation, then how can you say that neonatal deaths after homebirths were CAUSED by the homebirths? Pot...kettle...black?

I guess I'm wondering why you're so against homebirth across the board. It's admirable to try to save the world's children, or what have you, but the women I know who have had homebirths were all highly educated on the subjects of pregnancy, labor and delivery, and knew what to expect and what the risks were.

And there are risks everywhere (gasp - even in hospitals! How about that C-section rate!). We each have to balance risk and benefit and do what we think is best. Hospital delivery is not 100% safe either, and there are risks there that don't exist at home (i.e., the cascade of interventions, infection).

By Anonymous Anonymous, at 10:28 AM  

Amy,

Why do you care so much about home birth and what those of us who choose it think and feel? I think only 1% or less of women in this country even have their babies at home. This seems to be highly personal for you. What is motivating you?

Why don't you spend your energy working in your own field where you can make a difference?

By Blogger Mama Liberty, at 10:44 AM  

Why thank you. I'll stick to my myth and lies. I've read up on them and have chosen to follow them like the blithering idiot you seem to think that people who don't agree with your dissection of the studies.
Thank goodness we are dying off and our children do too! That way we can't wrongly educate them on the myth that pregnancy is a 'normal' thing huh? Good grief, shall we risk them reproducing too?! I'm scared for my daughter... what kind of people is she going to encounter if she decides to have a baby in her life? I shudder to think!
Why quibble... just be happy those of who can't or don't understand are declining in number proper quantitative numbers that Sailorman can point at!

By Anonymous Anonymous, at 10:59 AM  

Spoken like a true OB!

By Anonymous Anonymous, at 11:08 AM  

doctors did not discover water treatment- do not equate doctors with scientists--

By Anonymous Anonymous, at 1:00 PM  

Mama Liberty said...
Why do you care so much about home birth and what those of us who choose it think and feel?

I don't care about them, exactly. I just don't like misinformation in general. It is true that I fully support the rights of a woman to make choices which would negatively affect her fetus during birth (I'm completely pro-choice and given that it's a natural conclusion.) I just hate the idea of babies dying because people are, apparently, lying.

Why don't you spend your energy working in your own field where you can make a difference?

Part of Amy's job is to improve health. Fighting misinformation DOES improve health. in other words, this IS her field.

By Blogger sailorman, at 1:05 PM  

start here-- read 3 pages

http://hearth.library.cornell.edu/cgi/t/text/pageviewer-idx?c=hearth;cc=hearth;sid=923b27661b431234d17fad554dd72c37;rgn=full%20text;idno=4305922;view=image;seq=0015

By Anonymous Anonymous, at 1:34 PM  

Ummmm the table of contents? What gives?

By Anonymous Anonymous, at 3:03 PM  

"According to the CDC, prematurity, low birth weight, and maternal complications of pregnancy are still the top causes of neonatal death (at least they were in 2002). Home birth is not really a factor in deaths from prematurity or low birth weight (but good prenatal care might help), and mothers with pregnancy complications are probably going to wind up with hospital births anyway."

No one is suggesting that homebirth is going to increase national neonatal mortality rates. We are talking about the fact rate of neonatal death at homebirth is higher than the rate of neonatal deaths in the hospital.

Homebirth advocates have so many fall back positions that I feel like I am playing one of those domino games where you set them up and knock them down in series.

First we have: birth is safe because it is natural.

Oh, no, it isn't. Well, homebirth is as safe or safer than hospital birth.

Oh, no, it isn't. Well, there are deaths at homebirth, but no one could have prevented them.

Oh, no, that's not true. Well, obstetricians can't take credit for the fact that neonatal deaths rates are so much better than ever. It's because of public health.

Oh, no, that's not true either.

Then we have my favorite: Why do you care anyway?

How about because I think people deserve accurate information about their healthcare choices and all the information that I can find about homebirth is untrue. This forum is the first that I am aware of that actually exposes the myths and untruths and lies about how homebirth compares with hospital birth.

By Blogger Amy Tuteur, MD, at 3:57 PM  

Sailorman -

I think this post isn't just about Amy arguing against certain side points that homebirth advocates often bring up. It is also what these side points support:

The contention that since midwives have a history thousands of years old, they must be superior to doctors in managing birth. This belief is seriously undermined if it turns out that it is the research of doctors and scientists that improved neonatal and maternal outcome.

Doctors and scientists are considered anti-natural and anti-intuitive. Many proponents of homebirth seem to feel that Intuition and nature are better than logic and technology.

But if improvements in birth outcomes have overwhelmingly been brought about by logic (scientific method) and advances in technology, then this seriously undermines that idea.

I will go one step further, though. Midwives of this day and age will also not be responsible for any future decrease in the mortality and morbidity of neonates and their mothers, except they bring modern obstetrical practices and technologies into countries where they are not available.

Homebirths are the norm there. There are an estimated 10 maternal deaths for every 1000, and the neonatal mortality rate is 45 to 1000 births.

By Anonymous Amka, at 4:59 PM  

Amy,

You say that 48% of neonatal mortality was due to prematurity, yet you say infection has nothing to do with this. So are you saying that no prematurity can not be caused by an infectious process?

By Anonymous Anonymous, at 5:34 PM  

Anka,

I think this post isn't just about Amy arguing against certain side points that homebirth advocates often bring up.
I know why Amy is doing it--I'm just shocked that she has to.

The contention that since midwives have a history thousands of years old, they must be superior to doctors in managing birth. This belief is seriously undermined if it turns out that it is the research of doctors and scientists that improved neonatal and maternal outcome.
The belief doesn't even NEED to be undermined. It's not relevant ANYWAY. The failure of the home birth folks to see this is sheer lunacy.

I mean, come on. Do you have any idea how large "medicine" is, or even how large "obstetric medicine" is? If you want to make a comparison and say "well, let's see how accurate the modern medical world is in trying to evaluate obstetrics and birth" you'd have tens of thousands (maybe hundreds of millions?) examples in the last 20 years alone.

And those 20 years are much more relevant. As any historian will acknowledge, you can learn a lot from history: but you can learn MORE if the history was similar to what you are trying to decide. So what does it matter what people did in 1940, much less 1820?

The concept that someone would "validate midwifery" (or medicine) on the basis of a comparison of techniques between people long since dead is ridiculous. It would actually be funny, IF the home birth people wren't deadly serious.

Many proponents of homebirth seem to feel that Intuition and nature are better than logic and technology.

I know that, and find it depressing. It is shocking to me that they are able to obtain certificiation in an ostensibly science-based field if they reject some of the core precepts of science itself.

But if improvements in birth outcomes have overwhelmingly been brought about by logic (scientific method) and advances in technology, then this seriously undermines that idea.

No, it doesn't, which is why this is pointless. If your oponent is not arguing from a logical basis, it's impossible to convince them using more logic. it is very, very, similar to trying to convince an ID proponent. In fact, with every conversation the home birth crowd reminds me more and more of the many religious fundamentalists with whom I debate ID. They don't seem capable of changing their minds either--and like many here, they resort to every nasty techniques in the book.

I will go one step further, though. Midwives of this day and age will also not be responsible for any future decrease in the mortality and morbidity of neonates and their mothers, except they bring modern obstetrical practices and technologies into countries where they are not available.

I dno't actually agree on this. Midwives are, in theory, perfectly capable of scientific advances supported by good data. In fact, in some instances, their extremely limited focus serves to help them identify things, like the commonly cited Gaskin maneuver.

The problem, of course, is what they DO with that data.

By Blogger sailorman, at 6:22 PM  

you are starting from a premise that science was involved in what doctors do. From the beginning it was clear that they went against science in favor of what they thought was socially, morally or religiously the high ground despite - what science and scientists were pointing to and a few medical men who were also men of science . Now to weed out what was established convention and what is good practice and science-- even sweeping statements that are ridiculous like infectious states and clean environment, had and have nothing to do with maternal or neonatal health- and death.
and yet smoking mothers are a problem, BV, GBS now I just don't think you can really have it both ways- infections and maternal environment do have something to do with neonatal health or it doesn't

By Anonymous Anonymous, at 7:02 PM  

you are starting from a premise that science was involved in what doctors do.

No, I'm not. I don't give a whit about was "was" involved. I do not claim that merely because a procedure "is done" it "should be done."

From the beginning it was clear that they went against science in favor of what they thought was socially, morally or religiously the high ground

OK. But we are not AT the beginning. We are here, now.

Now to weed out what was established convention and what is good practice and science...

....requires good scientific data, properly applied. That's what you were going to say, right? Sorry I fininshed your sentence. Go run a study! Go explain that current practice is wrong! I mean, it's ALWAYS people who believe in change who promote it.

I don't understand why folks are always bitching "why doesn't anyone see my point? Why won't they believe me?" when all they have to do is go to school for an extra 5-7 years, do a post doc, get some grants, run some studies, write them up, and prove their point themselves. You can even skip the PhD part if you're smart, write well, and go for a blind review journal.

I mean, surely you weren't going to imply that you can "weed out" the good science from the bad science, without resorting to... science.

Were you?

Because it LOOKS like the home birth folks are simply trying to fight a battle over "socially, morally or religiously the high ground" and shit, we ALL agree it didn't work so well the last time. What, home birth is some sort of magical exception to the "guesses are not data" rule?

even sweeping statements that are ridiculous like infectious states and clean environment, had and have nothing to do with maternal or neonatal health- and death.
and yet smoking mothers are a problem,


I'm sorry, but I have absolutely no idea what you are trying to say here.

By Blogger sailorman, at 7:27 PM  

Sailorman wrote>>>"I'm sorry, but I have absolutely no idea what you are trying to say here."

re-read DR's posts..... that is what I am getting at!!!

By Anonymous Anonymous, at 7:57 PM  

Here's yet another example of Amy presenting her opinion as foregone conclusion...

We have already done some exploration of the major myth, that birth is inherently safe because it is natural

Do you think that birth is NOT natural? (oh, and that's yet another post of mine you never responded to). It's as natural as eating, breathing, peeing, pooping, lovemaking, aging, what have you. An inevitable end - indeed, natural. Who said birth was 100% safe because it was a natural human event? We're not stupid, Amy, we KNOW the high mortality and morbidity rates in past centuries, in 3rd world countries. You will only consider the worst kind of care - not professional midwifery care - and that's where you're standing on a deck of cards and lose your point.

First, this lie speaks directly to the unreasoning hostility of homebirth advocates to modern obstetrics. They are so desperate to deny obstetrics credit for its accomplishments, that they willingly ascribed them to other people.

Whatever are you talking about here? More details please. I happily ascribe a lot of credit to modern obstetrics. I don't necessarily think OB doctors are the end all be all of obstetrics, however.

the primary causes of neonatal mortality have never been infectious and public health measures did not contribute very much (if anything) to the decline of neonatal mortality.

It is actually quite funny to me that you can think anything like this. That you can think your post somehow proved this point. I would love to see some docs get ahold of this! Amy, you have really overdone yourself here. Have you EVER worked in public health, do you know anything about 3rd world medicine or real public health? Please do share your experience.

By Anonymous maribeth, CNM, at 9:38 PM  

Maribeth -

Amy has stated that she believes childbirth is natural. What she doesn't believe is that this makes it safe.

Babies who die at birth or shortly after birth are not saved by being born in a clean bed. Their problems are generally prematurity or asphixiation. There is evidence that late neonatal mortality (towards the end of the first 28 days) has improved because of public health measures, but not early neonatal mortality.

Public health has done a lot of good, but not this.

By Anonymous Amka, at 9:45 AM  

Maribeth, you seem eerily determined--almost fanatical--in your attempt to misinterpret the vast majority of Amy's posts.

When Amy says
"We have already done some exploration of the major myth, that birth is inherently safe because it is natural"

The myth starts at the "because."

Of course birth is "natural." So are eating, sex, vomiting, dying, wonds consumed by flesh eating bacteria, sepsis, embolisms, cancer, yadda yadda. But as you can easily see from my list, "natural" doesn't mean "safe" or even "desirable." THAT is the myth to which she is referring.

"Do you think that birth is NOT natural?"

She's said no. Why do you keep asking?

Who said birth was 100% safe because it was a natural human event?

You're misstating the position again. "100% safe" is easy to disprove, which is why nobody claims it. "Inherently safer" (which is what she was talking about, not what you 'wish' she was talking about) is the frequent claim, and the myth.

We're not stupid, Amy

I am much more blunt than Amy, I fear. I assume everyone I am talking to is intelligent when i first meet them. However, if you continue misrepresenting, misquoting, and generally attacking people based on thigs they did not actually say, I may be for=ced to conclude otherwise.

You will only consider the worst kind of care - not professional midwifery care - and that's where you're standing on a deck of cards and lose your point.

You are misquoting her, as usual. Can you stop doing that? I mean, make an argument, sure, but enough of the misrepresentation already.

Amy is on record (go search the blog yourself) for being supportive of highly trained and professional CNMs--who often practice in hospitals, FWIW. And of course the vast majority of the studies we have been discussing are of US midwives.

So it is entirely untrue that Amy is "only considering the worst kind of care," as you claim.


Whatever are you talking about here? More details please. I happily ascribe a lot of credit to modern obstetrics. I don't necessarily think OB doctors are the end all be all of obstetrics, however.

the primary causes of neonatal mortality have never been infectious and public health measures did not contribute very much (if anything) to the decline of neonatal mortality.

...I would love to see some docs get ahold of this! Amy, you have really overdone yourself here.

The beauty of the internet and the written word is the "prove it" principle.

So I say to you: Prove it. Go copy this blog. Go find some doctors who think Amy has "really overdone herself" here. Bring them here, and invite them to post.

But seeing as you are probably less likely to know what doctors think than she is (ask me some time and I"ll explain why this isn't an ad hominem attack) your post doesn't mean much without support.

Have you EVER worked in public health, do you know anything about 3rd world medicine or real public health? Please do share your experience.

As usual Maribeth, you're going on an ad hominem attack against Amy. What does it matter about her "experience"? She's right or she isn't. Can't you have an opinion--an educated and correct one--on public health without being a public health worker? You are being ridiculous.

And seeing as you provide no alternate explanation at all, just insults, this is pretty damn obnoxious of you.

She's given you the data. She's explained why she believes she is right. And--as usual--you run AROUND the data, to try to randomly attack something which is entirely unrelated to the data. Moreover, you seem to think that your "so there!" somehow affects conclusions on the data, which shows an utter lack of comprehension about how these kinds of decisions get made.

By Blogger sailorman, at 12:09 PM  

sailorman I think you just get too much adrenalin out of this.
the thing is I do and will ascribe improvements when they are due but not in the time line Amy subscribes to- the CDC even credits environmental clean up and disease control with the plunge in death rates === and if you don't think this is a current issue take a look at the 3rd world for a minute.
and do I have a right to an opinion even if I don't have a doctorate and run a study-- I can read history and listen to my elders quite well-- my Grandparents were born in the 1880 and 1890- my grandmothers had home births - so my parents are survivors of Homebirths they greatly loved their midwives and their wonderful old doc who would do in home care- my one grandma was a nurse and had went to nursing school in the 1920s -
as for understanding current information- as has been stated before the studies are just not big enough samples--so all the other extrapolation on both sides is a bit pointless...
I also think that studies are just like selected facts- depending on your inclination-- you know skinner and his rat box- well what would the rats have done if they could have left the box?

By Anonymous Anonymous, at 2:49 PM  

Sailorman, a lot of my (palpable) frustration has to do with the fact that Amy rarely responds to many questions, posts or points. Amy won't discuss most issues further, then continues on stating "A" is true as if conversation "B" and "C" never happened. I think the opening arguments of the source post of this thread exempify that.

You're claiming I'm twisting her words: truth is, I'm echoing what she refused to respond to. How would I change my opinion on something if she never dialogued about it? It feels like beating my head against a brick wall. I know I have been reactive, and angry - that's why.

Likewise, sailorman, I see you respond to me more than to anyone else (and disrespectfully, at that). I'm sorry I get your goat, but you're not the referee here. As you have problems with my style of posting, yours is not beyond criticism: let Amy defend, explain, or clarify herself instead of it being your job. Frankly, I wasn't talking to you.

Here's my point about public health: when international health teams institute safe motherhood programs, they don't implement modern obstetric care. They build wells and latrines, vaccinate, pass out soap, give simple birth kits and picture pamphlets out. Amka wrote Babies who die at birth or shortly after birth are not saved by being born in a clean bed but cleanliness (simple public health) a) prevents prematurity, a leading cause of neonatal mortality b) prevents tetanus, a leading cause of neonatal death and c) reduces the maternal mortality dramatically. Oh, but sorry, I forgot you only cared about the dead babies.

Amy writes In contrast, the primary causes of post-neonatal mortality (after 28 days of age) were chest infections 33%, gastro-intestinal infections 18%, congenital anomalies 6%. Right away we can see that none of the primary causes of neonatal mortality were infectious chest and GI infections are NOT infectious??? Later, Maternal mortality does include a large component of infection, but this did not respond to public health measures and was only controlled by antibiotics and NOT by handwashing?? It's pure delusion! You see why I was so confused. Amy harps on 'the other side' not giving credit where credit is due, then proceeds to build an entire post around doing the exact same thing.

So sailorman writes seeing as you provide no alternate explanation at all, just insults, this is pretty damn obnoxious of you . Exactly what alternate explanation do I need to provide to prove that the above statements are absurd? Was there some question in the post? Okay, then, my big exciting alternate explanation is: public health IS indeed responsible for much of the dramatic decline in morbidity and mortality of childbearing.

By Anonymous maribeth, CNM, at 8:07 PM  

Maribeth:

"You're claiming I'm twisting her words: truth is, I'm echoing what she refused to respond to."

No, Maribeth. You don't seem to understand what I write. You consistently miss the point and then gripe that I don't respond to you. I don't respond because you are always talking about a different topic from what we are actually discussing at the time.

Perhaps you don't read what I write very carefully. I know that you post only to criticize, so I could imagine that you scan my words to find an opening for snappy comeback. The problem is that your comebacks are not very "snappy" at all, since you missed my point and are usually criticizing something I never said or meant.

Maribeth, if you want to be taken seriously, you need to READ what I write and make sure that you are responding to what I actually said.

In addition, since I am already giving unsolicited advice, you need to know that you completely destroy your credibility when you resort to childish insults like "Have you ever worked in public health?" Virtually everyone recognizes that as irrelevant to the discussion at hand. If you feel the need to attack me, instead of my data, you've already conceded defeat before you started.

I didn't intend to single you out, Maribeth, but you keep singling yourself out by constantly asking why I am not responding to you.

By Blogger Amy Tuteur, MD, at 10:55 AM  

If you feel the need to attack me, instead of my data

Amy, that is not data, that is an opinion piece strung together with a lot of words and bias.

I think it is reasonable and expected that we (all) critique one another. I mean to challenge your biased assumptions and expressed falsehoods and make you explain yourself more fairly. Your language is biased; in example, your liberal use of the word data. We all know we can quote an author who proves our point.

You are arguing that OB medicine, specifically, OB and neonatal physicians, are more responsible for improvements in morbidity and mortality than public health is. I am interested first in your specific responses: do you think prematurity is not in part infectious? Do you think think maternal septic mortality was not infectious?

From the CDC report 'Achievements in Public Health, 1900-1999: Healthier Mothers and Babies':

Maternal mortality rates were highest in this century during 1900-1930 (2). Poor obstetric education and delivery practices were mainly responsible for the high numbers of maternal deaths, most of which were preventable (2). Obstetrics as a speciality was shunned by many physicians, and obstetric care was provided by poorly trained or untrained medical practitioners. Most births occurred at home with the assistance of midwives or general practitioners. Inappropriate and excessive surgical and obstetric interventions (e.g., induction of labor, use of forceps, episiotomy, and cesarean deliveries) were common and increased during the 1920s. Deliveries, including some surgical interventions, were performed without following the principles of asepsis. As a result, 40% of maternal deaths were caused by sepsis (half following delivery and half associated with illegally induced abortion) with the remaining deaths primarily attributed to hemorrhage and toxemia

I suspect we have different definitions of public health. If you think that my above questions again miss the point and constitute griping, please do further explain why.

I understand now you prefer a little stroking (hey, we all do). Amy, I AGREE that medicine and medical doctors have been ENORMOUSLY important in the decline of morbidities and mortalities of childbearing. I am so appreciative, and admiring of the degree of advancement and what it's done for mothers and babies. It's just my opinion that putting those advances ahead of public health advances (clean water, sanitation, vaccination, improved access to health care, presence of (any) birth attendent, etc etc...) is overzealous.

I think in your (admirable, and important) special interest in addressing the disproportionate burden of mortality in women and babies of color, we'll eventually find measures of simple public health and social welfare to be more important than medical technology. But that is just my opinion.

By Anonymous maribeth, CNM, at 2:43 AM  

Maribeth,

Here's what I wrote:

"Sepsis does have an infectious cause"

Here's what you wrote:

"Do you think think maternal septic mortality was not infectious?"

Do you see a serious problem here? I certainly do.

By Blogger Amy Tuteur, MD, at 10:58 AM  

Sorry Amy, thank you for the clarification. You only attributed the decline to antibiotics, however, and I'd argue that handwashing, sanitation, etc, played a role. I also think prematurity had (still has) an infectious basis.

By Anonymous maribeth, CNM, at 11:52 AM  

Here's another problem, Maribeth:

When was handwashing, etc. introduced?

When were antibiotics introduced?

When did maternal mortality start to decline?

I see another serious problem here. Do you see what it is?

By Blogger Amy Tuteur, MD, at 12:53 PM  

Maternal mortality rates were highest in this century during 1900-1930. Poor obstetric education and delivery practices were mainly responsible for the high numbers of maternal deaths, most of which were preventable....

The discovery and widespread use of antimicrobial agents (e.g., sulfonamide in 1937 and penicillin in the 1940s) and the development of fluid and electrolyte replacement therapy and safe blood transfusions accelerated the declines in infant mortality; from 1930 through 1949, mortality rates declined 52%


I see your point, but it occurs to me you're basically saying thank goodness that antibiotics were invented to keep poor medical practices from directly killing so many women. I suppose it is a case of which came first, the chicken or the egg. I'm not trying to discredit the advances of medicine. I'm just wondering why the disparage against public health? This is tangential, I know, and you'll likely take offense to its relevence, but Amy, if you could first institute public health or obstetric medicine in a remote village in Uganda, for example, which would it be? For me, advanced medicine simply CANNOT occur until public health is established. That is my point.

By Anonymous maribeth, CNM, at 1:49 PM  

Maribeth,

Nothing you've said disproves the basic fact that improvements in public health are NOT the reason for the spectacular decline in neonatal and maternal mortality. That is due to advances in medicine in general, and obstetrics and neonatology in particular. If homebirth advocates do not acknowledge this, and try to credit advances in public health, they appear foolish and spiteful.

By Blogger Amy Tuteur, MD, at 9:26 PM