Wednesday, September 05, 2007

Homebirth advocates don't want women to know

Every now and then I contribute to the Wikipedia article on homebirth. I generally add purely factual information and include the appropriate citations from the literature. Within a few days, a homebirth advocate comes along and deletes most of it. What is especially interesting to me is that they delete facts. It appears to be vital to the homebirth project to keep scientific information out of the hands of women. Evidently, women must not be allowed to make informed decisions.

Similarly, I occasionally post on homebirth blogs. This usually creates a flurry of indignation and, of course, deletion of facts. The classic example occured when I posted on Henci Goer's blog (see What led up to Henci Goer's refusal to debate? and Henci Goer has no answer ... again) where Henci Goer actually publicly proclaimed that I could post on her blog, but that any rebuttals of her claims would be deleted.

Yesterday I posted on The True Face of Birth. Rixa, who says she is writing her dissertation on unassisted homebirth, announced that "Due dates are nonsense." I posted to point out (complete with citation from MacDorman et al.) that due dates are important because the risk of stillbirth rises after the due date and rises steeply after 42 weeks. The post was, of course, deleted. So, I wrote again, and you can see how the debate developed:
It is revealing though not surprisng that natural childbirth homebirth advocacy depends on supressing the truth. I posted a paper (Fetal and Perinatal Mortality 2006) showing that the due date is far from arbitrary; there is a marked progressive increase in stillbirth rates after 40 weeks gestation. Rather than addresssing that issue (since presumably you have no actual data to address that issue) you chose to delete the post.

That's your prerogative, but it demonstrates more powerfully than I could that natural childbirth and homebirth advocacy is based in mistruths, half truths and out right deceptions. The only recourse when someone offers the truth is to delete it and hope that no one sees it. Go right ahead and delete this, too, but ask yourself: why does natural childbirth and homebirth advocacy depend on hiding the truth?
Rixa responded with a riff on authoratative knowledge:
I deleted your earlier post because I have seen enough of your comments elsewhere to know that calm, rational discussion will not occur. I want to keep this a non-hostile forum.

Plus the issue in my post wasn't stillbirth. Your comments were both hostile and irrelevant so I chose to remove them.

The real issue isn't who is "right" or "wrong." It's who gets to define reality and decide what counts and what doesn't. The power to speak authoritatively, to define what knowledge is orthodox and what is not, is an immense one. Western biomedicine currently claims ownership of authoritative knowledge in our culture.

Anthropologist Brigitte Jordan, best known for her book "Birth in Four Cultures," explains that authoritative knowledge is “the knowledge that within a community is considered legitimate, consequential, official, worthy of discussion, and appropriate.” ...

Debates about home vs hospital birth are so polarized because the opposing sides are really contesting deeply held paradigms. It's not quibbles over statistical data that's at stake. I doubt that the debates will accomplish anything except cement both sides more deeply in their own worldviews. It's like a Catholic trying to prove or disprove Buddhism based on Biblical teachings. You can't use totally different belief systems to prove or disprove each other...
Rixa deleted the rest, but I saved it. Here's my response and her reaction:
AT: "The real issue isn't who is "right" or "wrong."

There are two kinds of issues, philosophical issues and empirical issues. There are not right and wrong answers to philosophical issues; or, rather, the right and wrong answers depend upon your underlying philosophy. So, for example, your thinking about the death penalty is a philosophical issue.

The other class of issues is empirical. Empirical issues DO have a "right" and "wrong". Does the sun rise in the morning? That is an empirical issue and there is only one answer. No matter what your philosophy is, the sun will never rise in the evening.

The issue of whether a due date is important is an empirical issue, not a philosophical issue. It is an empirical fact that the stillbirth rate begins to rise after the due date and rises steeply after 42 weeks. It's probably the single most important piece of information that women need to know about due dates.

What a woman chooses to do about that information is a philosophical issue. Some women may feel that the increased risk justifies interventions and other women may feel that the increased risk is not high enough to justify any interventions. In either case, it is difficult to construct an argument that women can make an informed decision about due dates without that critical piece of information.

Rixa: My issue with due dates, though, is that the very term implies a level of precision that we simply can't attain. LMP and ultrasound still only give us rough guesses. Unless the woman knows her date of ovulation & conception precisely, we still can't know if she's really reached "40 weeks" or not...That issue is important and has implications for any study about correlating X factor with length of pregnancy.

There's also a great amount of stress about going even one day past the magic 40 week "due date." If a woman goes into labor the day before, she doesn't freak that she's "early." But if she goes one day over, she'll start telling everyone she's "late" and "overdue." Bizarre.

AT: For a woman with a 28 day cycle, LMP is quite accurate, and for women who have conceived with fertility medication or procedures, ovulation can be pinpointed almost to the hour.

It is interesting that when a woman goes into labor at 28 weeks, natural childbirth and homebirth advocates recognize that it is critical to have support available with the assumption that the baby is 28 weeks, and (appropriately) they don't suggest that the due date is wrong. So either we have to believe due dates, or we don't; there can't be one approach for premature babies and another for postdates.

What is unfortunate (from my point of view) is that claiming that due dates are arbitrary does not allow a woman to make an informed decision. It is a fact that stillbirth rates (and other complications) rise after the due date and rise sharply after 42 weeks. It is also a fact that the absolute risk of death is small. Therefore, a woman, when relying on her own values, can elect to accept the small increased risk that postdates poses. However, it is absolutely imperative that she knows what she is doing. She IS accepting an increased risk, particularly after 42 weeks.

Only a small fraction of postdates babies will die, but, unfortunately, it is not possible to tell in advance which babies those will be. Are many inductions unnecessary? Absolutely. However, it is important that women understand that obstetricians cannot tell in ADVANCE which are the necessary ones and which are the unnecessary ones. Since that is the case, what else can an obstetrician do besides recommend an induction?

Rixa: "Dr. Amy"
I guess I didn't make it clear--I don't want to debate with you on this forum. Please feel free to discuss issues on your own blog. I don't have the energy/time to delve into these issues with you and I do not feel we will achieve a rational conversation. I will assume you read this recent comment and remove it soon. (I tried finding an email address but your sites had none listed).

ps--to my readers: you can read some correspondence between "Dr Amy" and Henci Goer at the Lamaze Normal Birth forums ...
As I often say, homebirth advocacy is based on mistruths, half truths and outright deceptions. Therefore, it is especially important to delete factual information. Evidently homebirth advocates feel they have no choice; women cannot be trusted with the facts because, of course, the facts do not support their claims about homebirth.


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