Monday, July 31, 2006

How homebirth advocates twist information to mislead

Here is a classic example of misleading information presented on a homebirth advocacy website:
In the past, most Americans were born at home with lay midwives attending. The mortality rate for both mothers and babies was higher in 1900, at 700 maternal deaths per 100,000 births, than it is now... Obstetricians tend to emphasize that many women used to die in childbirth, implying that we should be grateful for current obstetric practice. However, even in 1900, the percent of women who died giving birth was only 7/10ths of one percent!
The author implies that the risk of dying in childbirth was trivial. Of course, if you consider that approximately 2 million women gave birth in the US in that year, that means that 14,000 women lost their lives in childbirth in one year alone. I don't think anyone would or should consider the deaths of 14,000 healthy young women in the prime of life to be a trivial event.

Just as important, the author "neglects" to mention that the maternal death rate in 1900 was approximately 100 times higher than it is today. In contrast to the 14,000 maternal deaths in the US in 1900, there were 396 in the year 2000, despite the fact that there were an additional 2 million deliveries.

Homebirth advocates say "even in 1900, the percent of women who died giving birth was ONLY 7/10ths of one percent!" The reality is that more than 14,000 women used to die in the US each year from complications of childbirth. The maternal mortality rate used to be 100 times higher than it is today. Had the maternal mortality rate remained at the 1900 level, approximately 28,000 women would have died in childbirth in 2000, instead of the 396 who actually died. Homebirth advocates don't tell you that though, because then you would understand what has happened. And if you understand what has really happened, it would be very difficult to take seriously other claims about homebirth. Evidently, they feel it is better to mislead.

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Saturday, July 29, 2006

The luxury of homebirth advocacy

It is no coincidence that homebirth advocacy and natural childbirth advocacy exist almost exclusively in countries with very low neonatal and maternal mortality rates. That's not a coincidence. Most homebirth and natural childbirth advocates tend to forget that worrying about an empowering birth experience is a luxury that was created by the spectacular success of modern obstetrics. Prior to that, most women worried about dying in childbirth or the even more likely prospect that their baby would die during birth or in the first day of life.

That luxury does not exist in the developing world. In some parts of the world, the lifetime risk of a woman dying from childbirth is 1 in 8. That is probably relatively close to what the risk of death from childbirth was prior to the advent of modern obstetrics. Think for a moment about what that means. Among a group of 8 young girls in tribe or settlement, 1 of the 8 would likely die in childbirth or of a childbirth related complication like postpartum hemorrhage. In contrast, the lifetime risk of maternal mortality in the US is approximately 1 in 2500.

One of the most irresponsible claims of the homebirth movement and the natural childbirth movement is that childbirth is not very dangerous at all, that "women's bodies have perfect knowledge of how to give birth." The fact that this claim is false and displays a stunning lack of understanding about childbirth is not a reason not to have a homebirth or natural childbirth. However, it does show a remarkable lack of gratitude to the people who make such things possible, the obstetricians who developed modern obstetrics and the obstetricians who practice today.

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Thursday, July 27, 2006

Experience vs. Knowledge

Responding to my comment that so much of what natural childbirth advocates have been told about childbirth and midwifery simply isn't true, Danielle says:
"I would say the majority of people debating here are here because of what they have *experienced*, not because of what they have been *told*!!!"
I know that many natural childbirth advocates would passionately agree with that statement, but let's take a closer look. There are two different questions that are raised by this statement. How have advocates experiences been mediated by what they have read? How much of what advocates claim as a knowledge base is actually true?

I would not think of disputing any woman's experiences, but I would ask whether the experience came before exposure to the natural childbirth advocacy literature or after. Certainly some women have bad experiences and then read the literature and find that it resonates with them. But those women seem to be few.

I would suggest that in most cases, advocates read the natural childbirth literature (or the homebirth literature, or the waterbirth literature) and that shapes their experiences. If the experiences came first, then we would find that these experiences throughout time, and across cultures. However, the descriptions of labor pain as "empowering", the reports of "orgasmic" birth, etc. seem to be restricted to white, Western, well-educated and relatively well off women who have given birth within the past 100 years.

Take waterbirth as an example. Essentially no one gave birth in water until Michel Odent told them that they should. If waterbirth represents an aspect of natural childbirth, it most certainly would have been practiced in other times and in other cultures. If the urge to labor in water were inherent, we should be able to find women who labored in water before Michel Odent made his pronouncements, and in places where people have never heard about Michel Odent or his colleagues. Yet that is not what we find at all. The urge to labor in water, indeed the entire practice of laboring in water, basically did not exist until a man made it up.

The second aspect of this issue is what natural childbirth advocates claim to "know" about childbirth that has nothing to do with what they personally experienced. A lot of the claims about the benefits of natural childbirth are knowledge claims, not experience claims. Natural childbirth advocates do not say: Natural childbirth was healthier for me and my baby. They say: Natural childbirth is healthier for mothers and for babies. A substantial portion of these knowledge claims are simply untrue.

For example:

"Birth is inherently safe because it is natural."

"The neonatal and maternal mortality rates in nature are relatively low."

"The neonatal and maternal mortality rates dropped dramatically in the last century because of better hand washing and cleaner water."

"Modern midwifery recreates childbirth as it existed in nature."

"The pain of childbirth is a result of the medicalization of childbirth."

"Epidural anesthesia is harmful to babies."

"If you blunt or eliminate labor pain, you will impair the mother-infant bond."

"Scientific research shows homebirth to be as safe as or safer than hospital birth."

These are all knowledge claims and none of them are true. A woman would only learn about them from reading the natural childbirth advocacy literature, because that is the only place that these claims appear. They do not appear in the medical literature and they are not things that can be directly experienced, or generalized from the experience of an individual woman.

I don't doubt that many natural childbirth advocates had bad experiences in the hospital or that they had better experiences with midwives. That's not surprising because, in most places, midwives are a lot nicer than doctors. However, I would claim that the interpretation of these experiences are mediated in large part by the natural childbirth literature (since nothing similar happened before the literature existed and nothing similar happens in places without access to the literature). Furthermore, since the natural childbirth literature is filled with myths, falsehoods, and outright lies, a good deal of the knowledge claimed by natural childbirth advocates is simply not true.

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Tuesday, July 25, 2006

"How can a man possibly understand the joy of unmedicated childbirth?"

Sometimes, all you can do is laugh.

I saw this statement on homebirth advocacy website, chastising the author of an article questioning why women might refuse pain relief in labor, and I have seen it quoted approvingly on other websites within the past day. Doesn't anyone see the irony?

Natural childbirth advocacy is a creation of MEN! Only a man could come up with the idea that labor pain is good thing. Consider:

Grantly Dick-Read
Michel Odent
Fernand Lamaze
Frederick LeBoyer
Robert Bradley

It is not the least bit surprising to me that men could create a theory that pain is good for women. What is more than a bit ironic is that women (natural childbirth advocates) would accept indocrination in what they are "supposed" to feel from people who never have and never could experience labor.

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Sunday, July 23, 2006

The function of pain in childbirth

What if pain in childbirth is an unnecessary remnant from human evolution?

Natural childbirth advocates often claim that the pain of childbirth brings a variety of benefits. Indeed, there are some who claim that the pain triggers a hormone cascade that is necessary for maternal infant bonding. Others insist that childbirth is not painful and is actually "ecstatic" and provides sexual pleasure. These varying theories hinge on the notion that the pain of childbirth adds something of value to the experience birth, and that the pain is good and beneficial. However, evidence derived from the study of ancient childbirth suggests that natural childbirth advocates have it precisely backwards. The pain of childbirth is not needed to trigger good things, it is vital to prevent maternal and neonatal death, and is a vestigial response that is no longer needed.

Before we consider ancient childbirth, it makes sense to think about the role of pain in the human body. Pain is almost always a sign that something is wrong, perhaps seriously wrong. Indeed, pain is so important to human survival that it can stimulate reflexive reactions. Put your hand on a hot object and you will actually begin pulling it away before you consciously feel the pain. That's because there are nerve circuits in the spinal cord that allow you to unconsciously perceive the pain and pull away, skipping the step of consciously noticing the pain so as to save time and limit damage.

When you think about it, there is no instance in which pain is not designed to protect against damage. At the level of the skin, pain tells us what is safe to touch and what is dangerous. At the level of bone, the pain of a broken bone is so great that it forces immobility, and that probably helps the bone to heal properly. The pain of disease makes people search for ways to diminish the pain, and perhaps improve survival from the specific problem. So, at the most basic level, there is no reason to believe that the pain of labor is beneficial in and of itself. Unless labor pain is different from all other types of pain of human existence, labor pain exists to warn.

Human childbirth has existed in its present form for millions of years. During that time, the death rate of both mothers and infants was extraordinarily high. Evolution would certainly have favored strategies that lowered the risk of death. Perhaps labor pain, like all other forms of human pain, existed to warn women to seek assistance.

Seeking assistance in childbirth may have lowered infant mortality by having help in situations like breech birth (which usually cannot be accomplished without some manipulation of the baby's body) and may have lowered the death rate from postpartum hemorrhage, because the assistant could massage a woman's uterus after birth. Assistance in childbirth must be very important from an evolutionary perspective because anthrologists report that all human societies have birth attendants.

According to Karen Rosenberg (a paleoanthropologist who studies human birth) and Wenda Trevathan (a biological anthropologist and trained midwife) writing in Scientific American special edition, New Look At Human Evolution, 2003:
... [W]e suggest that natural selection long ago favored the behavior of seeking assistance during birth because such help compensated for these difficulties. Mothers probably did not seek assistance solely because they predicted the risk that childbirth poses, however. Pain, fear and anxiety more likely drove their desire for companionship and security.

Psychiatrists have argued that natural selection might have favored such emotions—also common during illness and injury—because they led individuals who experienced them to seek the protection of companions, which would have given them a better chance of surviving [see “Evolution and the Origins of Disease,” by Randolph M. Nesse and George C. Williams; Scientific American, November 1998]. The offspring of the survivors would then also have an enhanced tendency to experience such emotions during times of pain or disease. Taking into consideration the evolutionary advantage that fear and anxiety impart, it is no surprise that women commonly experience these emotions during labor and delivery.
It would be quite ironic for natural childbirth advocacy if the role of pain in labor was to alert women to the inherently dangerous nature of childbirth, so they would seek assistance. It would also mean that labor pain has outlived its usefulness. Far from being beneficial, labor pain may turn out to have only harmful effects.

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Friday, July 21, 2006

Superiority

Whether natural childbirth advocates wish to acknowledge it, or not, they project an air of moral superiority, either implicitly or explicitly. Google "natural childbirth" and superior/superiority and you will find quite a few articles by natural childbirth advocates on its supposed superiority. There are also several articles by women who resent such claims of superiority.

Here are excerpts from an article by Margaret Talbot in the NYTimes Magazine:
... My first baby, born after a 24-hour labor during which I had requested -- O.K., bleated piteously for -- an epidural, nursed avidly from the moment he breathed air. And I couldn't take credit for a conscious decision to forgo anesthesia this time; I'd simply been swept downstream by the sheer force of a shorter, more intense labor. I was glad to have experienced a different kind of childbirth this time around and grateful not to have been up all night. I was lucky to have had with me a midwife (and a husband and sister) who made an unmedicated labor seem possible, without ever implying that it was the True and Only Way. But that is not to say, as natural childbirth's cheerleaders do, that I was in some way a better person for it. It's not even to say that without anesthesia I was more alive to the miracle of birth. Pain concentrates the mind, but what it concentrates the mind on is pain...

Natural childbirth, according to Ina May Gaskin, the president of the Midwives Alliance of North America, is "hugely empowering." After a natural birth, she said recently, "you have so much power you feel you could do anything. Women go on being grateful for that birth and will go on remembering it as a signal event in their lives that changed them."

This sort of belief has a long and not especially humane lineage. In 1847, when Dr. James Young Simpson introduced chloroform as one of the first anesthesias for childbirth, moralists derided it precisely because it vanquished the pain that women were supposed to feel as punishment for Eve's transgression...

Today's natural childbirth purists don't see moral punishment in pain but they do see moral superiority in refusing pain relief. They do see labor as a kind of performance, for which a woman can and should rehearse, and in which she can comport herself more or less admirably. They see it, in other words, as an opportunity to define the self. Maybe they hold fast to this ideal for the same reason people climb Everest or paraglide in the Andes. They regard labor as an extreme sport -- an ennobling physical challenge that we pampered First Worlders are supposed to courageously endure and savor. Spurning the palliatives of modern medicine is part of the drill, an emblem of virtue...

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Wednesday, July 19, 2006

Natural is superior ... unless it's not convenient.

I have argued repeatedly that the definition of "natural" childbirth is arbitrary and exists to convey approval of the things that the advocates like, and to convey disapproval and disdain for what they have not personally sanctioned. I have seen many arguments in response about the inherent superiority of natural functions and "what nature intended".

So here's my question:

If natural is "superior" when it comes to human reproduction, why is it acceptable to regulate fertility?

There is no doubt that regulating fertility is not natural. Nature "intends" for a woman to get pregnant as soon as possible after weaning a child, and to bear the maximum number of children she is physically capable of bearing. So why is it okay to ingest all sorts of chemicals, or to place technological devices inside the body or to surgically alter the body to interfere with this vital natural function?

Even "natural" family plannning is unnatural. Human ovulation is concealed. The fact that we now understand how the menstrual cycle works does not mean that it is "natural" to use this information to prevent conception.

Of course, it goes without saying that an abortion is completely unnatural.

So how is it that "natural" is superior, but it is perfectly acceptable to use drugs, devices and surgery to prevent pregnancy? I'll offer an answer: natural is "superior" for childbirth because that reflects the personal preferences of advocates, but it is not "superior" for fertility because that's simply not convenient for advocates.

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Tuesday, July 18, 2006

Maternal mortality

The homebirth movement propounds a variety of myths and lies about obstetrics in an attempt to deny obstetricians credit for their tremendous successes. One of the biggest lies is that 99% drop in maternal mortality achieved in the last century was due to "public health" measures like improved sanitation and handwashing.

The following information was taken from an article about maternal mortality in the underdeveloped countries. The focus of the article is applying what we have learned about maternal mortality in the US and Britain to save lives in poor countries:
During the 19th century, living conditions (nutrition, sanitation, etc.) in Europe and North America improved, and this resulted in sustained and impressive declines in infant mortality, and in deaths from infectious diseases among adults (e.g. tuberculosis), well before medical technology to fight these was developed.

During this period, however, maternal mortality remained high. For example, from 1840 (when the first maternal mortality statistics were available in Britain) to the mid-1930s, maternal mortality remained as high in Britain as it is in many developing countries today. Then, after nearly a century of stagnation, maternal mortality declined so sharply that within 15 years it was no longer a major public health problem. Why? Because the technology to treat obstetric complications became available, including antibiotics (first sulfa drugs and then penicillin), banked blood and safer surgical techniques. In 1934, there were 441 maternal deaths per 100,000 births in England and Wales. By 1950, there were 87, and in 1960 there were 39. Similar patterns obtained in other European countries and in the United States ...

In other words, it was not that women were less likely to develop obstetric complications, or more likely to survive complications in the absence of medical care, that led to low levels of maternal mortality in developed countries. Rather, it was the fact that women had access to treatment for complications... [F]or decades the focus of maternal health programmes was on antenatal care, screening of pregnant women, and training of traditional birth attendants to do clean deliveries. These activities were based on the assumption that most life-threatening obstetric complications can either be prevented or predicted...

The first antenatal clinics, which were introduced between 1910 and 1915 in Australia, Scotland and the United States, represented a new concept of care for pregnant women – the monitoring of apparently healthy women for signs of illness. It was generally believed ... that widespread use of antenatal care would reduce maternal deaths. But this did not happen...

The problem was (and still is) that the major causes of maternal death cannot be detected and averted during pregnancy. Post-partum haemorrhage, the leading cause of maternal deaths, can be caused by a number of events, such as a small piece of placenta being retained in the uterus, or the woman being exhausted after delivery. These problems cannot be predicted, even late in pregnancy, because they only happen during labour and delivery, or the post-partum period. Prolonged labour can be managed by medical intervention, such as use of drugs or caesarean section, but it cannot be prevented...

While some cases of infection will be prevented through clean delivery techniques, other cases of infection will still occur because infection can arise without being introduced from outside the woman’s body. For example, in the event of prolonged labour or prolonged rupture of the membranes without delivery, infection often arises from the damaged tissue itself.
So the 99% drop in maternal mortality achieved in the last century was due to the technology to treat obstetric complications such as antibiotics banked blood and C-section. It was not due to improvements in public health.

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Sunday, July 16, 2006

Why make outrageous claims?

Claims like Dr. Odent's about oxytocin and bonding are unsupported by scientific evidence. Why make such claims? The reason sheds some light on natural childbirth advocacy.

In most areas of life, most of us recognize that different choices are right for different people. No one would claim that their is an "ideal" number of children or an "ideal" form of birth control. What may be right for you and your family might not be the right choice for another woman and her family. Natural childbirth is a similar kind of choice. It is just one way to have a baby. It can be the right choice for some women, but it may not be the right choice for other women.

Yet natural childbirth advocates do not seem to be able to accept that natural childbirth is just one choice among many. There is a constant stream of claims, unsupported by scientific evidence, that are designed to show that natural childbirth is "superior". Of course, that would mean that women who opt for natural childbirth would be "superior" to other mothers.

Dr. Odent's claim, although especially ludicrous, is understandable in that light. The reflexive rush to his defense, despite the complete lack of scientific evidence, is also understandable in that light. No one wants to give up any claim to "superiority", whether it is based in fact or not.

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Thursday, July 13, 2006

Offensive

Dr. Michel Odent owes many women an apology for his offensive comments regarding maternal-infant bonding:
Women who choose to have Caesarean sections may be jeopardising their chances of bonding properly with their babies, a leading childbirth expert has claimed.

Obstetrician Michel Odent said that undergoing the planned procedure prevents the release of hormones that cause a woman to 'fall in love' with her child.

Speaking at a conference in Cambridge, Dr Odent warned that both C-sections and artificial inductions with drugs somehow interfere with the natural production of the hormone oxytocin.

The French expert said: "Oxytocin is the hormone of love, and to give birth without releasing this complex cocktail of love chemicals disturbs the first contact between the mother and the baby.

"The hormone is produced during sex and breastfeeding, as well as birth, but in the moments after birth, a woman's oxytocin level is the highest it will ever be in her life, and this peak is vital.

"It is this hormone flood that enables a woman to fall in love with her newborn and forget the pain of birth."

He added: "What we can say for sure is that when a woman gives birth with a pre-labour Caesarean section she does not release this flow of love hormones, so she is a different woman than if she had given birth naturally and the first contact between mother and baby is different."
In his zeal to criticize women who don't follow his "prescription" for birth, Dr. Odent has reached a new low.

Let's take his comments to their logical conclusion. If C-sections blunt the secretion of oxytocin (he provides no evidence for this), and that interferes with bonding, surely women who adopt (and therefore don't secrete oxytocin at the time of birth) must not be able to bond with their children at all. So, Dr. Odent, do adoptive mothers fail to bond with their babies? Do adoptive mothers have impaired relationships with their children?

Dr. Odent's comments are scientifically absurd, but more importantly, they are emotionally cruel. Of course, that is what you would expect from a movement that places such a high value on a self constructed sense of superiority.

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Tuesday, July 11, 2006

Why is the C-section rate so high?

Although the rising C-section rate has not produced the predicted increase in maternal mortality, it certainly accounts for plenty of morbidity, not to mention increasing medical costs. So who or what is at fault?

It is certainly a multi-factorial problem. It involves anesthesiologists and the types of epidurals they give. It involves the demands of patients and it involves the fear of legal action. If I had to point to the most important factor, though, I would say it is the attitude of patients. You might think that this has nothing to do with homebirth, but it is related in a way. The homebirth movement is prey to this attitude and actually promotes it. What am I referring to? I am talking about the widespread and erroneous belief that childbirth is not dangerous.

Obstetricians have been so successful that most people do not realize that childbirth has an inherently high neonatal and maternal mortality. Modern obstetrics managed to drop the neonatal mortality rate over 90% and the maternal mortality rate over 99% in the last 100 years. It is the direct application of medical technology, including C-sections, anesthesia, antibiotics, blood banking and neonatalogy that accounts for the current very low mortality rates. Take that away, and the mortality rates would skyrocket again.

At this point, many people (and homebirth advocates are among them) believe that childbirth has no risks for healthy women and their babies. Since most women are sure that nothing could or should go wrong, they are angry and horrified when something does go wrong. Then, of course, they sue.

A recent paper in the New England Journal of Medicine concluded that approximately 40% of malpractice suits are frivolous. That means that they have no basis in fact. There was never any evidence that anything was done wrong medically. Even when you consider the suits that have some basis in medical fact, the overwhelming majority return verdicts in favor of doctors. That's because, ultimately, the jury does not believe that the patient can show that the doctor did anything wrong.

Considering the fact that doctors win most of the time, you might think that lawsuits might be considered an inconvenience. Far from it! The average malpractice suit takes years to make its way through the legal system, involves multiple depositions and other demands, and it usually experienced by doctors as anguishing, even if they win. Most doctors will do a great deal to avoid being sued.

Almost all obstetricians are sued. Some are sued more than once. The best defense against a lawsuit for neonatal death or disability is an early C-section, the earlier the better. At this moment in time, a C-section is the legal equivalent of "doing everything that could be done". If an obstetrician has not done a C-section (even if a C-section would not have helped), he or she is in a virtually defenseless position.

The obvious result of this is that the threshhold for performing a C-section has dropped dramatically. The baby is breech: do a C-section even though the vast majority of breech babies can safely be delivered vaginally. Signs of potential fetal distress: do a C-section, even though the fetal monitor is a relatively crude measure of fetal well-being. I could make a very long list of situations in which a C-section is probably not necessary, but is done anyway so that the obstetrician is perceived as "doing everything that could be done.

How can this be fixed? As I said before, it is a multi-factorial problem, so it will take a multi-factorial solution. Nonetheless, in my judgment, one of the most important steps in the process is to institute no-fault compensation for parents of babies who die or are injured during birth. The main advantage of this system is that parents will not have to prove that a particular person injured the baby, only that the baby was injured. The parents and the baby will not have to give 1/3 of any compensation they receive to a lawyer. Neither will they have to wait for the money. Morally, it is a much fairer system. Disabled babies who are disabled through no one's fault are no less disabled than babies who are victims of malpractice. Their parents are no less stretched, financially and emotionally, than the parents of babies who were victims of malpractice. Shouldn't they also receive financial help to meet the need of their child?

A no-fault system will free doctors to make decisions based on medical factors, not legal factors. In my judgment, that would produce a dramatic drop in the C-section rate. Instituting a no-fault compensation system requires legislation, though, and there is not much chance of it happening soon.

In the meantime, patients can help lower the C-section rate by accepting realistic expectations. Childbirth is inherently dangerous to baby and mother. If you have a healthy baby, it is often because of the medical technology available and the judgment of the obstetrician. If you don't have a healthy baby, it is not necessarily anyone's fault, because there is an irreducible level of neonatal mortality. Once people appreciate the inherent danger, they will be less likely to sue, and the C-section rate can begin to drop.

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Monday, July 10, 2006

Natural childbirth: the myth of being more educated and therefore superior

As part of researching material for Homebirth Debate, I routinely visit other blogs, forums and advocacy sites. One thing I have noticed is the repeated mention that natural childbirth advocates are more educated than other mothers and the implication or outright assertion that this makes them superior to other mothers.

This seems to be a rather elitist view of parenting. It's pretty clear that women with greater education and greater financial resources are more likely to read about any subject than women who are less educated or less well off. Should we conclude, therefore, that a white, middle class, college educated mother who has read many books about child psychology and attachment parenting is superior to a Haitian mother who cleans hotel rooms, and therefore has no time to read such books? I don't think so.

Similarly, women who are natural childbirth or homebirth advocates are overwhelming white, well educated and relatively well off. They read about many things and childbirth is just one of them. Surely that's a good thing. I can't figure out, though, why that should make them better mothers. There is an underlying edge of contempt when many natural childbirth advocates refer to women who don't spend time and money (which they may not have) to "educate" themselves about their "childbirth options".

Finally, if the level of education were an indicator of how prepared or how committed a woman is to mothering, the top of the pecking order would not be natural childbirth advocates, it would be women obstetricians. They are undoubtedly the women who are most educated about childbirth by far. Some female obstetricians choose natural childbirth; most do not. So the bottom line is that choosing natural childbirth does not mean a woman is more educated, and being more educated about birth does not mean that a woman will choose natural childbirth.

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Sunday, July 09, 2006

American Academy of Pediatrics says waterbirth is not safe

One of the more unusual practices claimed to be part of "natural" childbirth is waterbirth. Waterbirth is not natural for any primates, does not have historical precedent, and was only invented and used in the last 25-50 years.

The American Academy of Pediatrics Committee on the Fetus and Newborn released a comprehensive report last year that waterbirth is not safe for babies. The report, Underwater Births, begins:
Throughout human existence, women have typically given birth to their offspring on land. Over the last 25 years, however, underwater birth has become more popular in certain parts of the world despite a paucity of data demonstrating that it is either beneficial or safe.1–22 Underwater birth occurs either intentionally or accidentally after water immersion for labor, a procedure promoted primarily as a means of decreasing maternal discomfort. A review of the available literature indicates that the risks of underwater birth to the newborn seem to outweigh the benefits, and caution is urged before widespread implementation.
After reviewing the existing scientific literature, the committee concludes:
The safety and efficacy of underwater birth for the newborn has not been established. There is no convincing evidence of benefit to the neonate but some concern for serious harm. Therefore, underwater birth should be considered an experimental procedure that should not be performed except within the context of an appropriately designed RCT after informed parental consent.

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Friday, July 07, 2006

Is the rising C-section rate really a problem?

One of the advantages of homebirth is a lower C-section rate. It is often claimed that C-section is dangerous for mothers and perhaps even for babies. There is no doubt that the C-section rate has risen dramatically during the past decades, yet the maternal and neonatal mortality rates have not risen in response. Doesn't that mean that C-sections are not as dangerous as homebirth advocates claim?

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Wednesday, July 05, 2006

Confusion about intrapartum death rates

There seems to be some effort to sow confusion about the intrapartum death rate in order to avoid the inescapable conclusion that homebirth is not as safe as hospital birth. We already know that more babies die as a result of homebirth. The intrapartum death rate shows that they die due to inappropriate care in labor, as opposed to other factors that may be unrelated to homebirth.

A higher intrapartum death rate does NOT mean that the same number of babies die in both groups, but the proportions are simply different from hospital birth. It means that in the homebirth group more babies die as a direct result of care than in the hospital group. Remember, virtually every study of homebirth already shows that a greater number of babies die at home than in the hospital. The fact that they die during labor means that the deaths are due to care in labor not other variable like a higher rate of anomalies.

Bottom line: More babies in total die at home birth than at hospital birth. Furthermore, the babies who die at home are more likely to die in labor rather than from other causes that are unrelated to homebirth.

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Tuesday, July 04, 2006

How DEMs make themselves look very foolish

It is hardly suprising that many health officials refuse to license DEMs when some clearly know so very little about childbirth. A licensed CPM describes her response to the news that the Border Patrol is training its agents to assist in emergency childbirth in the desert.

This CPM seems to feel that the only important factor in birth is the use of pain medication in labor. The post starts with lots of jokes that epidurals cannot be used by the Border Patrol, ha ha ha.

The sheer lack of knowledge gleefully displayed in very disturbing. In the CPM's world:

There are no abnormal births, so the Border agents don't need to know ANYTHING about childbirth.

There are no breech or transverse babies.

There are no twins.

There is no obstructed labor.

Postpartum hemorrhage can be treated with nipple stim.

All poor, malnourished Mexican women are low risk.

The CPM writes:
I would think a Licensed Midwife would much better be able to demonstrate normal birth without medications and medical paralysis.
Here's a newsflash. Chilbirth is not about epidurals. Poor malnourished Mexican women scrabbling to reach the American border to give their babies the gift of American citizenship are at high risk that their babies or they will die in unattended childbirth.

The logical conclusion from this is that CPMs who do not acknowledge the complications that can and do occur in unattended childbirth in malnourished women are hardly likely to be able to care for anyone in labor. If you don't know about complications, you won't recognize them and you clearly will not know how to handle them.

Finally, what happened to the veneration and respect accorded to the midwives of old? Most doctors would laugh and say that the accumulated knowledge of lay midwives could be transmitted in under an hour. I didn't expect the same attitude from a DEM.

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Monday, July 03, 2006

Political pressure exerted to change NICE resport

Evidentally, the NICE report generated shock waves in the British government even before it was published. The British National Health Service (NHS) has been promoting birth at birth centers and at home in an effort to lower costs. In addition to showing that homebirth probably increases the risk of neonatal death, the NICE study also showed that birth centers increase the risk of neonatal death. Dr. Crippen directs our attention to an article in yesterday's Sunday Telegraph.
Nice's draft guidance, which included a recommendation for all pregnant women to be told of a "trend towards a reduction in perinatal mortality" in hospitals, was submitted to the Department of Health nearly a fortnight ago.

Several days later - and ahead of its publication on June 23 - it was altered by Andrew Dillon, chief executive of Nice, after concerns were raised by the Department of Health. To the fury of his own experts, who felt that their message was being diluted, the wording was changed to: "There may be a risk of lower perinatal mortality" in hospital.

A source told The Sunday Telegraph: "There was an angry phone call between Andrew Dillon and representatives of the guideline development group.

"Concern over the safety of mothers and babies in midwife-led units was watered down. Many of the group felt this was totally unacceptable, but, because they are bound by confidentiality clauses, they cannot speak out publicly."
This revelation has both a political and scientific dimension. NICE is an independent organization and the government committed a political blunder in trying to supress the NICE conclusion. The scientific dimension is important, too. The government did not insist on the inclusion of additional scientific information that might have changed the conclusion. That's because there is no contradictory scientific information on this point. They simply pushed for a change in the conclusion.

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Saturday, July 01, 2006

More on intrapartum death

There seems to be some confusion about the meaning of the intrapartum death rate. Within obstetrics, the intrapartum death rate is considered to be a sensitive indicator of appropriate care. Hospitals are compared on intrapartum death rates, intrapartum death rates have been examined for deliveries at various times of the day or year to see if it reflects provider fatigue or training, and intrapartum death rates are routinely compared for breech and vertex vaginal delivery to determine if breech vaginal delivery is safe.

Therefore, intrapartum death rate is a valuable way to evaluate the safety of homebirth. I have reported previously on the very high intrapartum death rates in homebirth studies:

Murphy & Fullerton 2/1221 = 16/10,000

Johnson & Daviss 5/5418 = 9.2/10,000

Janssen 1/860 = 12/10,000

Northern Region 5/2888 = 17/10,000

I have also referenced studies that quote the hospital intrapartum death rates as in the range of 2-3 per 10,000. People have questioned the accuracy of this number. I offer two other, very large studies that place intrapartum death rates in the hospital in the same range. The Confidential Enquiry into Stillbirths and Deaths in Infancy in the UK. This was a study of 648,409 births during the year 1999 in England, Wales and Northern Ireland. From the report:
...since 1993 there was a significant downward trend in intrapartum related deaths... The 4th Annual Report (1997) found that, in 1994 to 1995, half of these cases had been associated with suboptimal care that was likely to have contributed to the outcome. A series of recommendations were made regarding training, assessment and supervision of health professionals involved in caring for women and babies in labour. Many initiatives at national and local level have occurred in response to these and it is pleasing to see a downward trend in deaths of this type. The number and rate of deaths in this category, weighing 1 kg and over, have fallen from 529 (0.77/1000 total births) in 1993 to 398 (0.62/1000 total births) in 1999.
In other words, in the year 1999, the intrapartum death rate for all babies over 2.2 pounds was 6.2/10,000. This includes premature babies and babies with congenital anomalies. The death rate for low risk babies at term is substantially lower. So the intrapartum death rate for ALL babies was lower than the intrapartum death rates found in studies of homebirth.

Stephanson et al. reported on all intrapartum deaths in Sweden from 1991-1997 in Time of Birth and Risk of Intrapartum and Early Neonatal Death (EPIDEMIOLOGY 2003;14:218 –222). They studied 694,888 births and found an intrapartum death rate of 1.2/10,000 for babies at term, including high risk pregnancies. The rate for low risk pregnancies is undoubtedly lower.

Based on the four studies I have quote, the intrapartum death rates are substantially higher for homebirth (up to 8x higher) than for hospital birth. Since intrapartum death rates are a much more sensitive indicator of the quality of care than overall perinatal mortality rates, it is quite clear that the studies done thus far suggest that homebirth is far less safe than hospital birth.

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