Homebirth Debate

A professor of statistics says ...

Bravo, maria! Maria asked Henci Goer the question that sparked the debate on her site. She has not settled for the non-answer that Goer supplies or for the fact that my posts were deleted. She went to someone whom she believes is an independent expert.

Ok, I posted this to a prof. in statistics and here is his response:

The study I am looking at is this study:
http://www.bmj.com/cgi/content/full/330/7505/1416

The following explanation was given by Johnson and Daviss about their study:
http://understandingbirthbetter.com/section.php?ID=31&Lang=En&Nav=Section

Some people say they have used the wrong comparison groups and that the correct comparison would prove that homebirth has triple the neonatality rate of hospital birth.

***
OK, here’s my take on it…

When I read the executive summary of the BMJ, I was struck by it’s modest claims in the results. By modest, I mean that it essentially reported the percentages of differing outcomes within it’s own data set. It was the conclusion, however, that struck me: it claims that their study group was similar to a group not in the study, namely, low risk hospital births in the US.

That seems to be the basis of the criticism. The comparison group has one obvious difference that masks for lots of other potential discrepancies: it was retrospective data. The authors of the study actually point this out in the study, however, so, to me, it isn’t fair to fault them for making the comparison. Perhaps they could have added a footnote to the conclusion in the exec summary, but that’s a bit picky. The disclaimer is clear in the discussion section:

"Regardless of methodology, residual confounding of comparisons between home and hospital births will always be a possibility. Women choosing home birth (or who would be willing to be randomised to birth site in a randomised trial) may differ for unmeasured variables from women choosing hospital birth…."

Consistent with this disclaimer, the biggest factor (in my opinion) is the demographics of their study group. This is visible in Table 1, which shows the characteristics of the mothers in the two groups:

- More women above the age of 25
- Likelihood of having already given birth is much higher
- Typical education levels are higher
- 95% had partners—which I would wager is significantly larger than the comparison group, whose rate is reported as N/A

Their study group is a self-selecting subpopulation of women—they are different from other women in ways that move them to choose a birth method that is out of the "main stream." This fact alone (supported by the items I just listed) suggests to me that they were better prepared for birth, and more aware of risks and of ways to handle them.

They did attempt to sort the data from the Nat. Center for Health Stats into "low risk" mothers, in order to make a better comparison. Assuming that sorting method valid, they arrive at the result that their group is, essentially, equivalent to the in hospital "low risk" group. Not shocking, given the kind of mom in their population.

I hope this is helpful.
***

Now my question is, what numbers did Amy Tuteur use to come to her comparison of homebirth being triple the risk of hospital birth. Where can I find these numbers and how are they a better comparison?

I think in the end, on one hand, eventhough this study has lots of merrit, the homebirth advocates should maybe not take it as a decisive study about the safety of homebirth, as they tend to do now, saying 'see!'

However, I do not think Amy's claims are grounded either so I would like to present to this prof. the numbers Amy is talking about and see what he comes up with.

Henci, would you please refer me to where I can find the numbers Amy is talking about? My apologies if they are posted here before!

Thanks!
maria.

ps: I asked two other people knowledgeable in statistics to look at this and I am waiting for their responses as well

****

Maria, I will refer you to the data and explain what I am talking about. Don't hesitate to ask additional questions or request additional data if you think it will be helpful.

The original problem:

According to Johnson and Davis, when analyzing the different intervention rates of home and hospital:

We compared medical intervention rates for the planned home births with data from birth certificates for all 3 360 868 singleton, vertex births at 37 weeks or more gestation in the United States in 2000, as reported by the National Center for Health Statistics [Births: final data for 2000. National vital statistics reports. Martin JA, Hamilton BE, Ventura SJ, Mencaker F, Park MM. Hyattsville, MD: National Center for Health Statistics, 2002;50(5)]

When analyzing the different mortality rate of home and hospital, Johnson and Davis used a group derived from out of date homebirth studies. I have always thought that was strange. Why not use the neonatal mortality data of the group that served as the comparison for interventions?

I went back and looked at the neonatal mortality data for this group, the EXACT group that Johnson and Daviss felt was the perfect comparison for intervention rates. I did this by reviewing the exact same paper that Johnson and Daviss used... Looking at the raw data we find a death rate of 0.9/1000 (white women, age 20-44, 37+ weeks, 2500+gm).

The hospital neonatal death rate for white babies at term of 0.9/1000 is not corrected for congenital anomalies, pre-existing medical conditions, pregnancy complications or multiple births. The true rate is substantially lower. Nonetheless, we can make an important comparison. Johnson and Daviss reported a neonatal death rate at homebirth of 2.7/1000 (uncorrected for congenital anomalies, breech or twins). The neonatal death rate in the comparison group THAT THEY USED was less than 0.9/1000.

So now we have an explanation for why Johnson and Daviss used two different comparison groups. They used one group (births in the year 2000) for comparing medical interventions. The neonatal death rate in that exact group was 0.9/1000, half the rate of neonatal deaths at homebirth. They supressed that information by using an entirely different group (drawn primarily from the 1970's and 1980's) instead of using the death rate from the year 2000.

Here's where you can find more about the new explanation: Johnson and Daviss acknowledge the validity of my criticism.

Johnson and Daviss have recently "re-analyzed" their own data and lowered the homebirth neonatal mortality rate: Johnson and Daviss: If at first you can't trick them, try, try again.

Labels: Henci Goer, Johnson and Daviss

posted by Amy Tuteur, MD @ 12:30 PM

Henci Goer's theory of information access

Over the last several days, Henci Goer has deleted multiple posts of mine that offered detailed analysis of current homebirth controversies and links so people could read them for themselves. Now she posts this gem:

...In light of what has gone on with this thread, I will add a new rule: You will respect my authority as moderator to declare a moratorium on a topic. I posted that there had been enough information and resource links on the issue of the MANA 2000 home birth neonatal mortality statistics for people to make their own evaluations...

Here is my response (soon to be deleted there, but still available here):

You're joking, right?

YOU decided that there is "enough" information and resource links. What do you think is going to happen if there are more? Do you expect people to fall down dead from information overload?

There is absolutely no legitimate reason to limit the presentation of relevant information. The ONLY reason to limit the presentation of relevant information is to prevent people from finding out the truth.

I have no need to continue this discussion. I think I have made my point and hammered it home repeatedly. I only dropped in because you wrote about me personally and you lied. I honestly cannot believe that you were so careless. It is so easy to find out the truth about me and my credentials, but you never even bothered. Your contempt for the truth about something so obvious and easily checked should be a warning to others about your contempt for the truth about obstetrics.

Labels: Henci Goer

posted by Amy Tuteur, MD @ 11:34 PM

Henci Goer responds as predicted

Henci Goer has made me look like I can predict the future.I have been waiting for several days for her to address the fact that the Johnson and Daviss study ACTUALLY showed that homebirth has a neonatal death rate that is triple that of hospital birth. Here's what I wrote 10 hours ago:

Head over to Henci Goer's "Normal" Birth Forum and see how she is struggling, too. I've made two main claims that she KNOWS are true. First she deleted the claims and the supporting data. Then she had the unmitigated gall to pretend that I hadn't presented the supporting data. That was easy for everyone to understand; THEY had already seen it. Therefore, she let me put the links back up. Over the last several days, she has struggled to come up with a response. She's apparently in a bind. She obviously knows what the truth is and does not want to be caught in a falsehood. On the other hand, she certainly does not want women to know that my claims are true.

I expect that her answer will be the usual mix of aspersions about my credentials, and some baffling, high faluntin' conglomeration of technical language that will mean nothing and will allow her to pretend she has answered when she has not. It would be much easier, and far more ethical, to simply tell the truth.

Here's how she finally responded:

...Anyone who wants a calm, reasoned, scholarly explanation of the caveats of making appropriate statistical comparisons with the MANA 2000 study should [read Understanding Birth Better]. It does a better job of responding to Tuteur than I can do, which is not surprising since the author is an epidemiologist, and I am not.

As for Amy's mention of other deaths that I omitted from my calculation, this is a prime example of how she misuses data. The "other deaths" were not neonatal deaths. They were intrapartum deaths and therefore were not relevant to a comparison with hospital-based neonatal deaths. Indeed, Amy's persistent confusion over what is encompassed by "neonatal deaths"--this is not the first time I have pointed this out to her in this Forum--brings to mind Andrew Zang's comment: "He [or, in this case, she] uses statistics the way a drunken man uses lamposts--more for support than illumination.

FACT: Johnson and Daviss have now "adjusted" their data to claim that the neonatal death rate at homebirth in 2000 was 1.1/1000. Goer has not disputed that and has not explained why they "suddenly" realized that they made a mistake in their own paper.

FACT: The neonatal death rate for low and moderate risk women in the hospital in 2000 was 0.34/1000. Therefore, the neonatal death rate at homebirth in 2000 was TRIPLE the neonatal death rate in the hospital. Goer has not denied that either.

She can try to change the subject, she can try to pretend it doesn't matter, she can cast insults in my direction, but no one is fooled.

Addendum (7/6, 1:17 PM): No doubt people will be shocked, shocked to learn that Henci Goer responded to the simple, direct questions by deleting them.

So here's where I am with this: Aside from responding to Amy's assertion that she is qualified to discuss mortality stats and I am not, I have deleted Amy's posts along with your responses to Amy's attacks on my integrity. ... I think there is enough information in this thread and the links and sources provided in the posts that anyone who wants to make their own evaluation of the Johnson and Daviss paper, can do so. Therefore, I would like first to thank those of you who contributed positively to the discussion and second to declare that we are done with the topic of the MANA 2000 stillbirth and neonatal mortality statistics.

She doesn't appear to think much of the intelligence of her own readers if she believes they will be fooled by this.

Even such a short paragraph contains a lie. I never said that Goer is unqualified to discuss statistics. Quite the contrary. I said that she is qualified to discuss statistics and therefore, she knows what I have claimed is true. That's why it is so important to expunge any reference to it.

Labels: Henci Goer

posted by Amy Tuteur, MD @ 11:05 PM

Pathetic

Science demands that critics be answered with scientific evidence and well reasoned arguments. Ideology demands that critics be silenced. Homebirth advocates are nothing if not ideologues. Henci Goer cannot rebut my criticisms, so she must delete them.

Here's her latest response:

The last time you posted to this Forum, I set ground rules for you: you would have your opportunity to state your case and make one rebuttal to my response, and then we were done. I'm going to reinvoke that rule and delete all of your posts that appear after this one.

I'm not aware of any SCIENTIFIC forum that allows one rebuttal and then deletes criticism. However, Goer apparently feels she has no choice since she cannot rebut criticism. She posted the following, under the assumption that I cannot respond, but just because I cannot respond on her message board does not mean that I am silenced.

Goer says:

1. You have provided no source for the allegation that the CDC reports a higher perinatal death rate at home births. I have tried various search combinations, but I am unable to find your source. If you write back with the source so I can review it, I will not delete your post, and I will respond to it.

LOLOL. I already provided the source, and the link, to the CDC Wonder statistics for Linked Birth/Infant Death datasets. That's what Goer deleted! Now she can leave the impression that I didn't provide the source even though she knows that's a lie.

She continues:

2. You have supplied no information about the training of DEMs or how it compares unfavorably with the training of other midwives ...

My claim, the American DEMs have less education and training than ANY midwives in the industrialized world is true, and Goer knows it.

3. I will not rehash the argument over the Johnson and Daviss study. My response is elsewhere on this Forum.

She gives up. How could she do otherwise? Johnson and Daviss have already admitted that they used the wrong group for comparison.

It goes on in the same vein. I will not bore you with the rest. Henci Goer's response is pathetic, but it is the only response available for someone who is incapable of debating medical or scientific professionals.

Even more pathetic: Not content with the inanities that she has already posted, Goer decided to add an additional flourish.

I hit the CDC's most recent report on perinatal mortality in 2003. If you know Tuteur, you will not be surprised to hear that it says nothing about care providers.

Has she no shame?

She already deleted the link to the data, so that she could pretend it was never posted. Now she arbitrarily picks an unrelated paper and claims the data is not in there. No surprise since it is a paper about something else entirely.

This episode demonstrates one thing definitively. Henci Goer ignores and eliminates data that does not support her claims. She can't address it, she can't rebut it, so she justs omits it.

Labels: Henci Goer

posted by Amy Tuteur, MD @ 9:44 PM

Goer cannot rebut the claims

To her credit, instead of deleting my post, Henci Goer boldly tries to address it:

The link you inserted for the WHO quote did not work, but I tracked down the quote by searching on the terms "World Health Organization" "April 2006" and "home-like." Those who know you will not be surprised to hear that you misinterpreted the WHO statement, which is about "home-like settings" in hospitals not home births. The WHO sources its statement to

Hodnett ED et al. Home-like versus conventional institutional settings for birth. The Cochrane Database of Systematic Reviews, 2005, 1, article number CD000012.

Without a source for the NICE statement, I will not venture to comment on what you are likely to have taken out of context or misrepresented except to say that it hardly seems likely that U.K. health care policy would promote home birth if it posed excessive risk, which, of course, it doesn't.

Finally, the blanket accusation that U.S. direct-entry midwives have less training than other midwives in industrialized countries requires no denial because it is fatuous. The person who made it offered no comparison data to substantiate the claim. In fact, it would have been impossible to do so. Midwifery training varies from country to country as does scope of practice. In many countries, midwives do not function independently but under the supervision of obs who set policies and make medical decisions. In some countries, they function the way intrapartum nurses do here and don't even catch babies. The training needed for practice in these situations is different than that needed by a midwife working independently who takes full responsibility for her clients. What is more, other than in the Netherlands, midwives are almost always trained to conduct hospital births exclusively, which is a whole different animal from home birth. To sum up, there is nothing to "deny" because the accusation has no substance. The real question is, "Do certified U.S. direct-entry midwives receive adequate training to properly care for women intending home births and their infants in the antepartum, intrapartum, and postpartum periods?" To answer it, one has only to show that the NARM certification process for midwives is rigorous and thorough and that to achieve certification, a midwife must demonstrate that she has the requisite knowledge, skill, and experience to care for women appropriately at out-of-hospital births. End of story.

End of story? I don't think so. Here's my response, posted to her website:

Those claims were mine. Maria quoted them here without attributing them to me.

Ms. Goer, you did not manage to rebut, either claim, both of which are quite simple:

1. The WHO says homebirth increases the risk of neonatal death

2. US DEMs (including CPMs) have less education and less training than ANY midwives in the industrialized world.

Marsden Wagner himself acknowledges that the WHO strong disagreed with him on his personal opinion that homebirth is safe. He writes about it proudly in his chapter, Confessions of a Dissident, in the book Childbirth and Authoratative Knowledge by Brigitte Jordan.

Moreover, you did not even address the latest CDC statistics from the linked Linked Birth/Infant Death 2003-2004 dataset. The data show that homebirth with a direct entry midwife has double to triple the neonatal death rate as hospital birth for low risk women.

And as long as we are discussing this issue, I will mention two additional points that you have never addressed:

1. MANA (the Midwives Alliance of North America) has been collecting safety data on homebirth since 2001. They have publicly offered the data to those who can prove they will use it for the "advancement" of midwifery. Even those people must sign a legal non-disclosure agreement preventing them from revealing any data to anyone. In contrast, the US and state governments make all birth data available each year on the internet. MANA's data almost certainly show that homebirth with a CPM has a much higher neonatal death rate.

2. Over a year ago, we argued about whether Johnson and Daviss used the correct comparison group in the BMJ 2005 study. I said that the correct comparison group was low risk hospital births in 2000. With that comparison (which Johnson and Daviss left out of the paper), they had ACTUALLY showed that homebirth with a CPM had a neonatal death almost triple that of hospital birth. You gave all sorts of excuses as to why they didn't need to use that group. Johnson and Daviss have since publicly acknowledged on their onw website that I am correct. You have not acknowledged it, and instead (as far as I can tell) deleted the posts you wrote in support of the wrong control group.

3. Maria pointed out to you in another post that the World Health Organization 2006 report on perinatal mortality (which shows that the US has a lower rate of perinatal mortality than Denmark, the UK and the Netherlands) and that this cannot be reconciled with your public claims that the US has a higher rate of perinatal mortality than other first world countries. Fortunately, you now acknowlede that the US perinatal mortality rate is comparable to other developed countries.

Finally, I would appreciate it if you would stop insinuating that I am not who I say I am, that I do not have the credentials I list in my CV (Harvard '79; BU School of Medicine '84; Boston's Beth Israel Hospital internship, residency, staff appointment OB-GYN, Brigham and Women's Hospital staff appointment, Harvard Medical School Instructor in Clinical Obstetrics and Gynecology) or that I am in the employ of ANY organization. A public apology for your completely baseless, fabricated accusations would be appropriate. If you promote such obvious and easily checked falsehoods about me, people might begin to think you are using the same tactic to promote homebirth.

In case you decide to refuse to post or to delete this entry, readers can find it on my website.

Labels: Henci Goer

posted by Amy Tuteur, MD @ 10:12 AM

Henci Goer and the truth

Henci Goer continues to have great difficulty with the truth. She is putting her own credibility with laypeople in jeopardy when she makes misleading claims about facts that are so easy to check.

Someone wrote the following on the Lamaze message board:

1. Homebirth increases the risk of neonatal death. This is accepted and acknowledged by the WHO, the CDC, NICE (The National Insitute for Health and Clinical Excellence), a healthcare watchdog in the UK, among other major health organizations.

2. American direct entry midwives have less education and training than any midwives in the industrialized world.

Henci, do you have more information about this? Thanks!

Here's Goer's disingenuous response:

Both statements are gross falsehoods. Here is a quote from Care in Normal Birth: A Practical Guide, which is published by the WHO:

So where then should a woman give birth? It is safe to say that a woman should give birth in a place she feels is safe, and at the most peripheral level at which appropriate care is feasible and safe (FIGO 1992 [FIGO is the international Ob/Gyns professional organization]). For a low-risk pregnant woman this can be at home, at a small maternity clinic or birth centre in town . . . (p. 12)

World Health Organization. Care in Normal Birth: A Practical Guide. Geneva: World Health Organization; 1996.

And here is a quote from Sheila Kitzinger, writing in this year's March issue of Birth:

In September 2007 the UK National Institute for Health and Clinical Excellence (NICE) issued clinical guidelines on intrapartum care of healthy women and their babies during childbirth. Under "key priorities" it stated: "Women should be offered the choice of planning birth at home, in a midwife-led unit or in an obstetric unit." Information suggests that for "women who plan to give birth at home or in a midwife-led unit there is a higher likelihood of a normal birth, with less intervention" (p. 77).

Kitzinger K. Letter from Europe: home birth reborn. Birth 2008;35(1):77-8.

As for the canard that U.S. direct-entry midwives are poorly trained, a perusal of the North American Registry of Midwives (NARM) website gives the lie to that.

Goer's quote from the WHO is out of date. The WHO said in April 2006:

Home-like settings for childbirth are associated with reduced likelihood of medical intervention. The evidence shows that the number of spontaneous vaginal births is higher, breastfeeding initiation more common and maternal satisfaction better in home-like institutional birth settings compared to conventional institutional settings. However, the evidence shows an increased risk of perinatal mortality, the reasons of which are not fully established. Thus, there is an increased need for monitoring early signs of complications in these home-like settings. (my emphasis)

As far as the NICE report is concerned, Goer didn't even answer the question. She was asked if NICE reports a higher rate of neonatal mortality at homebirth, and they do. From the same report that Goer quoted:

... intrapartum-related perinatal mortality (IPPM) for booked home births, regardless of their eventual place of birth, is the same as, or higher than for birth booked in obstetric units.
* If IPPM is higher, this is likely to be in the group of women in whom intrapartum complications develop and who require transfer into the obstetric unit...
* When unanticipated obstetric complications arise, either in the mother or baby, during labour at home, the outcome of serious complications is likely to be less favourable than when the same complications arise in an obstetric unit.

Goer tried to sidestep the direct question that she was asked about DEM qualifications. American DEMs have less education and training than ANY midwives in the industrialized world. There's no denying it and she didn't deny it.

Obviously, neither claim is a falsehood, so why did Henci Goer say they were?

Labels: Henci Goer

posted by Amy Tuteur, MD @ 3:53 PM

Henci Goer can't prove it but ...

Anyone in need of a laugh should check out Henci Goer's latest post about me.

"I don't know if you ran across that thread while surfing this Forum, but some of us--including me--theorize that "Dr. Amy" is a disinformation strategy of the American College of Ob/Gyns. We can't prove it, of course"

It just like the rest of the stuff Henci Goer makes up. She can't prove it, but she writes it anyway.

Who is Henci Goer and why should anyone be listening to her? It appears that she has no credentials in obstetrics, midwifery, public health, epidemiology or statistics. Apparently she hasn't done graduate work in anything. She describes herself as an "independent expert", which is just another way of saying an "expert in her own mind."

One thing we can say for sure: If she can't figure out who I am, despite my articles, book, websites, etc., she obviously doesn't know how to do research.

Labels: Henci Goer

posted by Amy Tuteur, MD @ 6:07 PM

Henci Goer: Can you say "projection"?

You just can't make this stuff up.

Someone asked Henci Goer about my claim that the perinatal mortality rate in the US is low. Here is her response:

I'm not sure of the context here, but if Amy Tuteur is saying that our perinatal mortality rate is low, that is just not true. They are, in fact, shamefully high for a developed country. They fall woefully short of Healthy People 2010 goals, have been stagnant for years, and are on the rise. In some areas, notably Washington, DC, where there are large populations of low-income black women, our rates rival those of developing countries. Nothing that Tuteur says can be trusted to be sound information. She is well known for selective reporting, taking things out of context, and, um, to put it politely, mistating the facts.

Let's parse that statement.

"... if Amy Tuteur is saying that our perinatal mortality rate is low, that is just not true."

Actually, it is true, and Goer either knows it or should know it. According to the World Health Organization 2006 report on perinatal mortality, rates of perinatal mortality range from 4/1000 to over 110/1000. The US perinatal mortality rate is 7/1000. That puts in ahead of the Netherlands, the UK, Denmark, Ireland, Luxembourg, and Portugal. It has the same perinatal mortality rate as France, Japan and Monaco. This is quite remarkable considering that the US has the highest risk population of any industrialized country. On a scale extending from 4-110/1000, 7/1000 most definitiely qualifies as one of the lowest rates in the world.

"They are, in fact, shamefully high for a developed country."

Another false statement. They are below average for countries in the developed world, and they are below the perinatal mortality rates for countries which are touted by homebirth advocates for their higher rates of homebirth.

"[US perinatal mortality rates] have been stagnant for years, and are on the rise."

Wrong again. Does Goer read the scientific literature? Fetal and Perinatal Mortality, United States, 2003 by MacDorman et al. is the most recent comprehensive assessment of perinatal mortality in the US (published February 2007). According to the report:

The mortality rate for perinatal definition I [infant deaths of less than 7 days of age and fetal deaths of 28 weeks or more gestation]declined by 26 percent from 1990–2003 ...

A decline of 26% is neither "stagnant" nor "on the rise".

"In some areas, notably Washington, DC, where there are large populations of low-income black women, our rates rival those of developing countries."

The perinatal mortality rates among low income women of African descent are higher than those of white women. That's because African descent is risk factor for prematurity. The perinatal mortality rates are similar for women of African descent in other industrialized countries, but we have a much larger proportion of women of African descent among our population. Goer knows, or should know, that this tells us nothing about the state of obstetrics in America.

"Nothing that Tuteur says can be trusted to be sound information. She is well known for selective reporting, taking things out of context, and, um, to put it politely, mistating the facts."

Let's look at Goer's statement in its entirety. Selective reporting, check; taking things out of context, check, mistating facts, check; and as an added bonus, outright falsehoods such as claiming that US perinatal mortality is high when it is actually low, and claiming that US perinatal mortality is rising when it has actually dropped by 26%.

Labels: Henci Goer

posted by Amy Tuteur, MD @ 12:43 AM

Poor Henci Goer, still afraid

Henci Goer has never been able to defend her fabricated claims against my presentation of the scientific evidence. Not surprisingly, she has deleted most of my posts in order to avoid the embarrassment of having no response. Of course, she has banned me from her site after explicitly claiming she would not do so. I expected all of those responses, but she still managed to surprise me.

Here's my favorite part:

"If you search this Forum's posts on "Tuteur," you should turn up our exchange and see my defense of these studies, and how I handled her."

She's actually encouraging people to search for our "exchange" after she deleted most of it. That's the ONLY way she knows how to handle criticism ... erase it.

My second favorite part:

"Some weeks ago, someone e-mailed me asking who she was. I said that I didn't know, but it might be interesting to poke around on the internet and find out. A week or so later, my correspondent got back to me. She wrote that she could verify that Amy is a real person, but not that Amy is an M.D., much less an obstetrician."

So the woman who promotes herself as an "expert in research" can't even find out that a real person exists! If she can't manage to successfully research and discover the obvious, how can she be trusted to research the obstetric literature?

By the way, if you want to follow Goer's suggestion and "see my defense of these studies, and how I handled her", the exchanges she deleted are here:

Goer fils to address specific criticisms of the MacDorman study
There's no debate if the other side gives up
Goer tries to avoid the issue
What better confirmation that I am correct? Henci Goer cannot respond
A public challenge to Henci Goer
Goer refuses public debate. What does she have to fear?
What led up to Henci Goer's refusal to debate
Henci Goer has no answer ... again

Labels: Henci Goer

posted by Amy Tuteur, MD @ 7:00 PM

Ridicule

We have looked at the philosophical underpinnings of the homebirth movement including the rigid dualisms of nature/technology, female/male and home/greater world; the veneration of pain; and the implicit or explicit moralism. We have looked at the rhetorical tactics of the public efforts of the movement, including the invocation of tradition, the (often erroneous) claims of safety, the appeal of "choice" and the accusation of turf battles.

I have noticed another characteristic which seems fundamental to the homebirth movement, and the attempts to advance it. It is striking to me because it nullifies the claimed professionalism and scientific basis of the homebirth movement. I am referring to the pervasive use of ridicule as a form of argument and a defense against difficult questions. This extensive deployment of ridicule as a rhetorical device and as the first and frequently sole defense against challenging questions is in stark contrast to the formalism, the marshalling of evidence, and the statistical analysis that is the hallmark of true scientific inquiry.

At first, I thought ridicule was restricted to homebirth advocates who like to post on blogs, since ridicule is a staple of many debate blogs. After examining a large number of homebirth websites and publications, interacting with a few homebirth professionals, and reading the professional literature of homebirth, I have become convinced that ridicule is a cornerstone of homebirth advocacy.

Let's look at some examples:

Marsden Wagner, in Choosing Cesarean Section,, in the journal The Lancet, cannot resist. Starting with a quote from the Girlfriend's Guide to Pregnancy about the benefits of schedule C-section, he continues:

This statement from a popular US paperback illustrates the degree to which society appears to condone women choosing caesarean section and doctors committing insurance fraud..."

"Elective CS is convenient; it allows the doctor to get closer to “daylight obstetrics”."

"Having a highly trained obstetrician surgeon attend a normal birth is analogous to having a paediatric surgeon babysit a healthy 2-year-old."

Ridiculing both doctors and patients in a scientific journal? This is what passes for "discussion" in the professional homebirth movement.

Look at articles in other professional journals:

Why do women go along with this stuff? Kitzinger, et al. Birth 2006 Jun;33(2):154-8.

A Butcher's Dozen, Wainer, Midwifery Today 57, Spring 2001.

The Assault on Normal Birth: The OB Disinformation Campaign, Goer. Midwifery Today 63, Autumn 2002.

Fish Can't See Water, Wagner, Int J Gyn and Ob, 75, supplement s25-37, 2001

Look at Henci Goer's recent comments to me when asked specific questions about homebirth research:

"All I can say is you seem to be suffering from a case of "my mind is made up; don't confuse me with the facts."

" ... you will allow me and other normal birth advocates to gain insight into how adversaries of normal birth like you think while providing me an unparalleled opportunity to expose and dismantle their fallacies, illogic, and the extent to which they are willing to misrepresent the evidence. I couldn’t ask for a better teaching tool, so, please, fire away...

...I’m happy to spend the time. Lamaze International pays me by the hour."

"you want a fair, fact-based debate on birth issues about as much as Bill O'Reilly wants one on political issues."

The pervasive use of ridicule, primarily of obstetricians, but of patients as well, highlights the fact that homebirth advocacy is a belief system, not a scientific endeavor, and throws into sharp relief the inability of professional homebirth advocates, like Henci Goer and Marsden Wagner, to address scientific issues in a serious, respectful, statistically sound, and, above all, scientific manner.

Labels: Henci Goer

posted by Amy Tuteur, MD @ 6:58 AM

Henci Goer has no answer ... again

Henci Goer still can't give a straight answer to a straightforward question. Here's what I posted on her message board:

... I went back and looked at the neonatal mortality data for this group, the EXACT group that Johnson and Daviss felt was the perfect comparison for intervention rates. I did this by reviewing the exact same paper that Johnson and Daviss used... Looking at the raw data we find:

2,824,196 births to white women at term (37+ weeks), see Table 2
and
2,602 deaths of white babies weighing more that 2500 gm see Table 6
for
a death rate of 0.9/1000.

That's before congenital anomalies, breech and twins are excluded from the hospital group.

Johnson and Davis reported the following:

"After we excluded ... three babies with fatal birth defects, five deaths were intrapartum and six occurred during the neonatal period. This was a rate of 2.0 deaths per 1000 intended home births. The intrapartum and neonatal mortality was 1.7 deaths per 1000 low risk intended home births after planned breeches and twins (not considered low risk) were excluded."

If the congenital anomalies, breeches and twins are added back in, the death rate in 2.7/1000.

So, the neonatal death rate for white women at term in the year 2000 was 0.9/1000 and the neonatal death rate at homebirth was 2.7/1000. This is almost 3 times higher than the hospital death rate. Chi square analysis shows this to be statistically significant (p is less than 0.005)...

Here's what she wrote back:

Amy, Amy, Amy, give it a rest. I'm going to paste in my response to the excess neonatal death rate argument you made in the Lamaze blog some weeks ago. As I pointed out, you were using the wrong statistic for making the comparison then, and you are still using the wrong statistic now.

What would a REAL answer have looked like? A real answer would have investigated exactly where and how I obtained my numbers. Did I include the correct subgroups? Did I exclude the appropriate subgroups? Were my mathematical calculations correct? Obviously, Goer didn't take the time to do any of that. She simply offered the lame "apples-oranges" comment that she offered before. She touts herself as "an expert in the obstetric research", but she doesn't even take the time to analyze the actual statistics.

How dumb does she think you folks are? I'm sure you won't offer any public criticism, but even the staunchest supports of homebirth must be wondering why she cannot offer detailed, statistically based arguments.

Labels: Henci Goer

posted by Amy Tuteur, MD @ 9:52 AM

What led up to Henci Goer's refusal to debate

It is important to remember what led up to Henci Goer's refusal to debate. Although she has always avoided debating any medical or scientific professional, she had no public policy on the matter before last week. Furthermore, she seemed eager enough when I initially questioned her on two specific occasions and responded vigorously. What changed? It turned out that over the course of several weeks she was losing no less than 3 separate "debates" on specific issues on the Lamaze site. That's when she decided to promulgate and publicly announce her decision to limit debate with me. Personally, I don't think the timing was a coincidence. On three separate issues, she could not rebut my criticism.

What were the issues?

1. The Johnson and Daviss paper

In my judgment, this is the most important of the three issues that we were discussing. The Johnson and Daviss paper is the keystone of the public debate about homebirth. Of all the papers on homebirth, it has the fewest methodological errors. Unfortunately, the findings in the paper do not justify the conclusions. That's because Johnson and Daviss deliberately chose to use the wrong comparison (cohort) group in order to make homebirth look "safe" by comparison. That's hardly suprising since the researchers were committed public advocates of homebirth, the study was commissioned by homebirth advocates and was funded by a homebirth advocacy organization.

Lamaze published a screed on its website condemning ACOG's claim that there is no scientific evidence to support the safety of homebirth. Seven different homebirth advocates contributed to this essay, and the Johnson and Daviss paper figured prominently. When I posted my criticism of the paper in response, it was ultimately Henci Goer who responded. In the next step, I provided a detailed response.

Johnson and Daviss quote a neonatal death rate at homebirth of 1.7-2/1000. The neonatal death rate in the comparable hospital group is 0.3/1000 or less. The appropriate conclusion drawn from the Johnson and Daviss data is that the neonatal death rate at homebirth is more 5 times higher than the neonatal death rate at hospital birth! Not only have Johnson and Daviss NOT shown that homebirth is as safe as hospital birth, they have actually shown that homebirth is considerably more dangerous for babies than hospital birth.

There was no response to this, no attempt at rebuttal. In support, I quoted the Rochon article on prospective cohort studies:

“Selection bias occurs when there is something inherently different between the groups being compared that could explain differences in the observed outcomes.

It is important to keep in mind the effect the choice of comparison groups will have on potential selection bias when evaluating a cohort study...
Readers should recognise the potential for selection bias in all cohort studies and carefully consider possible sources of bias..."

Selection bias is the technical term for the serious problems with the Johnson and Daviss study. Both control groups used in the study are inherently different from the homebirth group in prognostic factors including risk level, race and year of delivery. Therefore, the conclusions of the study are invalid.

That comment is not visible because it is still "in moderation" almost two weeks later.

2. The MacDorman paper

This paper purports to show that C-section increases the risk of neonatal death. Henci Goer cited it approvingly on her personal blog. I posted my criticism of the paper, in detail. The most important point is that MacDorman relied on birth certificate data that is known (from other studies) to underreport risk factors and complications. Therefore, many of the "low risk" women in the C-section group are most assuredly not low risk. Henci Goer responded with a more technical version of "it doesn't matter". Then I quoted her own words back to her:

In your essay When Research is Flawed: The Safety of Home Birth, you say:

"The study doesn't investigate whether the choice to birth at home was at fault in neonatal deaths: The investigators note that 10 of the 20 babies who died had diagnoses of congenital heart disease or respiratory distress. An additional three babies had major congenital anomalies. They do not say whether the deaths occurred at home or in hospital, nor do they speculate about how the choice of birth setting may have affected neonatal outcome in individual cases. The investigators could have reviewed the medical records on these 20 deaths, which would have provided a more accurate picture of whether home birth care affected outcome, but they did not."

So in the case of the Pang study, you thought it was quite important that the investigators actually document the connection between the cause of death and the place of birth... It is important in the interpretation of the Pang study and it is equally important in the MacDorman study. I will venture to say that you know as well as I do that C-sections did not cause the neonatal deaths in the MacDorman study.

Goer accused me of "misrepresenting" the study but could offer not even a shred of evidence on that point.

3. Goer claimed on her blog that there has been no systematic attempt to study methods of uterine closure at C-section, even though this respresents a serious issue for women attempting VBAC:

What is shocking to me is that after reading that, I tried to find studies comparing different techniques and materials with respect to scar strength and was shocked that I could not even find any randomized controlled trials, let alone a systematic review on this topic. I would have thought this was an important issue, but apparently obstetricians do not deem determining what surgical techniques produce the strongest scar a question worthy of research.

. But that's simply not true. I provided citations for 9 separate papers and then went on to say:

I just showed you studies about single vs. double layer closure. They are not the only studies of uterine scar integrity. There are studies comparing types of uterine incisions (classical vs. transverse) and there are studies investigating the results of using different suturing materials. You may not be familiar with the studies about suturing materials because many were done by infertility specialists. They have a very keen interest in minimizing any tissue reaction in surgery on the tubes or the uterus (as in the case of repair of uterine developmental defects). If you like, I can compile a list for you. The point is, though, that those studies exist and it is wrong to suggest that no one has looked into the effects of incision type, closure type and suture material on uterine scars. All three have been investigated extensively.

Not surprisingly, Goer had no comment.

So the decision to limit what I can write on her blog did not arise spontaneously. It occured in response to the fact that she could not rebut my arguments on three distinct issues. Of course she refuses to participate in a public debate of her claims. She knows she would lose, because she has already lost on 3 separate occasions.

Labels: Henci Goer

posted by Amy Tuteur, MD @ 6:59 AM

Henci Goer refuses public debate. What does she have to fear?

From Henci Goer's blog:

"Well, at least we agree on something: The true spirit of science does, indeed, include willingness to defend one's position publicly, as I have been doing here and have said I am willing to continue doing. To repeat what I have written before, you are welcome to post a criticism to any analysis of mine. I will respond. That will make our positions both clear and public. Readers will then have everything they need to decide which one of us suffers from a case of "my mind is made up; don't confuse me with the facts." But I won't be baited. Your posts on this Forum--including this one--and the Lamaze blog make it abundantly clear that you want a fair, fact-based debate on birth issues about as much as Bill O'Reilly wants one on political issues. I won't play that game. You have your own blog for your rants. You will get no platform for them here or from me."

So let me get this straight. The woman who makes her living wondering why her "side of the story isn't being told", now refuses the opportunity to publicly debate with a medical professional? Ms. Goer lamented in her 2002 article, The OB Disinformation Campaign:

Have you wondered, as I have, what is going on? Why is our side of the story nowhere to be heard? ... Why are mainstream media rife with the grossest misinformation about cesarean section, VBAC, induction, epidurals-you name it-with nothing, nothing coming from our side other than an occasional tidbit tacked on in the name of balanced reporting, but clearly not meant to be taken seriously?

So, Ms. Goer, why are you suddenly backing down? Why are you withdrawing? Why have you publicly announced that you won't participate in any debate unless it is rigged to favor you? What do you have to fear?

I know what you have to fear: the exposure of many of your claims as nothing more than misinformation, half truths and in some cases, outright lies, and the inability to defend the shoddy scientific papers on which they are based. Ms. Goer, your claims are "junk science". You use the veneer of scientific language and statistics to mislead women who are looking for accurate information. As you said yourself: "If you "talk the talk," few will look behind the facade to see the weaknesses in logic or reasoning."

You can continue to deny it, but your reply is nothing more than a refusal to publicly debate your claims. You will hide within the safety of your own blog where you can delete anything that makes you look bad.

In conclusion, I find your reference to Bill O'Reilly quite ironic. Bill O'Reilly is a bully who can only "debate" within the safety of his own show, where he is free to rig the debate and silence opponents. He never "debates" anywhere where he is not explicitly in control. I have offered you a public opportunity to debate a medical professional in any neutral forum of your choosing. You have refused and you have offered no counter proposal. You will not come out from behind the electronic protections that allow you to rig the debate, silence unwelcome criticism, and delete information that shows you are wrong. In a way, I don't blame you. Your claims would be eviscerated in short order, and that must be prevented, even at the cost of publically acknowledging that you are afraid of any debate that you can't control.

Labels: Henci Goer

posted by Amy Tuteur, MD @ 8:22 AM

A public challenge to Henci Goer

Dear Ms. Goer,

As I have already written (and has you have deleted from your own site), the true spirit of science is the willingness to present, and the ability to defend, your positions publicly. I believe that your public announcement, in advance, that you will deliberately delete scientific criticism, rather than respond to it, is the ultimate confirmation that you cannot defend the positions that you present to lay people. I believe that your unwillingness to defend your positions is the ultimate confirmation that there is no evidence to show that homebirth is as safe as hospital birth. There is also no evidence to support the smear tactics that you use against modern obstetrics and obstetricians.

So I am offering a public challenge to debate and defend your positions and the scientific papers you depend on for those positions. You may not wish to hold it within the context of a support forum on the Lamaze site. In that case, we can hold it here, or you can create a new forum on the Lamaze site, or your personal site, or we can hold it jointly on two sites so there is no chance of one person changing the other persons comments.

You write for lay people who cannot really evaluate the scientific validity of your arguments. If your claims are really true, it should not be difficult to defend them in a debate with me. Indeed, it could only increase respect for your point of view, if you could defend your positions.

I look forward to your response.

Labels: Henci Goer

posted by Amy Tuteur, MD @ 10:29 AM

What better confirmation that I am correct? Henci Goer cannot respond.

Over on her Lamaze blog, Henci Goer has recently published a post that I find to be quite remarkable. I have posted several detailed critiques of various papers within the homebirth literature, including the Johnson and Daviss paper and the MacDorman paper on cesarean section. After I took apart her responses, point by point, with scientific citations, she has refused to respond.

As I wrote in previous posts, I take this as a sign that she has no effective response, and that my criticisms of the homebirth literature are correct. Now, she has publicly announced that she will not participate in any real debate with me. I simply cannot imagine a more powerful confirmation that she cannot refute the serious criticisms of her positions.

It is easy, oh so easy, to write for the lay public because they don't have the familiarity with the scientific literature, nor the understanding of statistics, to disagree or point out deficiencies in her argument. However, as I have maintained all along, it is much harder to debate with people who do know the scientific literature. In fact, it is so hard, that it must be avoided. A true debate with professionals would reveal that there is no scientific evidence that shows homebirth to be as safe as hospital birth.

Here is what Henci Goer wrote on her own blog in a post entitled An open letter to Amy Tuteur:

So, Amy, after thinking things over, I've come up with a new set of rules of the game: In future, if you disagree with something on this Forum, you are welcome to take your best shot, but you only get one bite at the apple. I'll respond, but any further posts you make on the same topic will be deleted.

Is there a more powerful confirmation (short of an outright admission) than a public declaration that any debate will be rigged? I would be allowed one attempt to present my position and no follow up; indeed any follow up I posted will be deleted! Of course it would; the assumption is that I will be correct, that my criticisms would not be easily dismissed. Therefore, it is imperative that they be deleted before anyone who understands them could read them.

The true spirit of science is the willingness to present, and the ability to defend, your positions publicly. A public announcement, in advance, that you will deliberately delete public criticism, rather than respond to it, is the ultimate confirmation that homebirth advocacy is not science; it is opinion and nothing more.

Update: Evidently, I'm not allowed even "one bite at the apple". I submitted the last two paragraphs of this post as a response to Henci Goer's An open letter to Amy Tuteur. It was promptly deleted.

What is especially compelling about these events is that Henci Goer is familiar with the principles of statistical analysis and is knowledgeable about the homebirth literature. Therefore, she is capable of understanding my analysis of the homebirth literature and my criticisms of various papers. That's why it is so very important to rig the debate. She understands what I have written; she cannot refute my analysis; she must do whatever is necessary to hide that fact from other proponents of homebirth and natural childbirth. The Johnson and Daviss paper used the wrong comparison (cohort) group. There is no refutation for my analysis; therefore, it must be hidden, and if presented, it must be expunged. The MacDorman paper relied on data that is known to be highly unreliable. There is no refutation for my analysis; therefore it must be hidden, and if presented, it must be expunged.

Is there any homebirth advocate who is knowledgeable about statistics and scientific literature who is willing to present their claims and defend their claims to their medical and scientific peers? Evidently not. Women who are thinking about homebirth or natural childbirth should consider this when evaluating the claims of homebirth and natural childbirth advocates. They run away and hide when challenged by scientific or medical professionals. They know that their claims will not withstand scientific scrutiny. That's why they can only be presented to lay people who cannot offer any substantive challenges.

Labels: Henci Goer

posted by Amy Tuteur, MD @ 12:17 PM

Where we stand

I have consistently maintained that there is no scientific evidence that shows homebirth to be as safe as hospital birth. Virtually every study done to date shows an excess rate of preventable neonatal deaths in the range of 1-2/1000. There are a number of studies that CLAIM to show that homebirth is as safe as hospital birth, but they do not. Even homebirth advocates recognize that papers such as the Farm study demonstrate nothing about homebirth, and they don't argue the point any longer. When pressed, they ultimately retreat to only two or three papers, recognizing that the others are not defensible.

The paper that is cited most often is the Johnson and Daviss paper Outcomes of planned home births with certified professional midwives: large prospective study in North America published in the BMJ in June of 2005. This paper has the fewest methodological problems of any pro-homebirth paper. Nonethess, it still has methodological problems so serious as to render the conclusions of the paper invalid. As I have described many times, Johnson and Daviss used the wrong group of women to compare to the homebirth group. Instead of using low risk white women who gave birth in the hospital during the same year, they compare homebirth in 2000 to data in other people's studies from the years 1969-1991 (predominantly papers from the late 1970's and early 1980's). This is completely unacceptable for several reasons:

1. Since the neonatal death rate at hospital birth dropped consistently from 1969 -2000. Therefore, neonatal death rates prior to 2000 were higher than they were in 2000. Johnson and Daviss tried to compare the homebirth death rate in 2000 with the hospital birth death rate from approximately 25 years earlier!

2. You cannot compare data in one paper to an amalgamation of data derived from disparate papers done by other people. Johnson and Daviss actually acknowledge this in their paper, writing: "Direct comparison of relative mortality between individual studies is ill advised, as many rates are unstable because of small numbers of deaths, study designs may differ (retrospective versus prospective, assessment and definition of low risk, etc.), the ability to capture and extract late neonatal mortality differs between studies, and significant differences may exist in populations studied with respect to factors such as socioeconomic status, distribution of parity, and risk screening criteria used." Then they promptly ignore their own explanation of why such comparisons cannot be valid, and proceed to make the comparison.

3. At the time the Johnson and Daviss paper was written, the US government had already published statistics for births in the year 2000. These statistics are quite detailed, and are broken down in a variety of ways (by cause of death, by race, by state, etc). The appropriate comparison group for homebirth in 2000 is hospital birth in 2000. That data was publicly available at the time Johnson and Daviss wrote their paper. That data shows that the neonatal death rate in the hospital in 2000 was substantially lower than the neonatal death rate at homebirth in 2000.

I have been talking about this issue for months, but it has only recently started to gain traction in the homebirth community. Several interesting things have happened in the last few days.

1. I posted this critique on the Lamaze website. The first response, from Judith Lothian, was rather vague, and unsupported by any evidence. Henci Goer wrote a more detailed response which did not address at all the main point of the critique. Two days ago I posted a direct question to Henci Goer: the comparison group in the Johnson and Daviss is inappropriate, yes or no? To their credit, Lamaze did not remove the post. Thusfar they have not answered it either, despite the fact that it is a very simple question. I believe I know why; they are aware that the comparison group is inappropriate.

2. One of the posters on this site who has vociferously defended homebirth recently revealed that she teaches statistics on the college level. I asked her the same question I asked Henci Goer. She has posted multiple responses that attempted to duck the issue. Now that I have asked her to answer just one question: is the comparison group inappropriate? Thusfar she has declined to answer. I believe I know why; she knows that what Johnson and Daviss did is not a defensible statistical analysis.

3. An associate of Johnson and Daviss posted on this website yesterday, apparently at the behest of Dr. Johnson. He has invited me to write him privately. I much prefer to have this debate in public and would value the opportunity to read his defense of his statistical methods. I'm a little confused as to why he is asking me to write to him; he could easily write to me. My e-mail address is posted prominently on the site.

In addition, Ms. Haas, Dr. Johnson's associate, suggested that I submit a rapid response letter to the BMJ. This is also confusing to me. Rapid response letters, as the name suggests, are published immediately after the release of the article. The rapid responses for the Johnson and Daviss article ended back in August of 2005. It is much too late to submit a rapid response now.

In summary, I have no doubt that the comparison group used by Johnson and Daviss was inappropriate and that, therefore, the conclusion that homebirth is as safe as hospital birth is invalid. The events of the last few days suggest to me that knowledgeable homebirth supporters know this, too.

Labels: Henci Goer

posted by Amy Tuteur, MD @ 3:49 PM

Goer tries to avoid the issue

Over the past several days I have been participating in a discussion on the Lamaze forum. As I detailed in a previous post (ACOG homebirth policy), my substantive claim is that there is no scientific evidence that homebirth is as safe as hospital birth, and the studies that claim that homebirth is as safe as hospital birth show nothing of the kind.

In particular, the Johnson and Daviss study, which is the most widely quoted because it has the fewest methodological errors, used the wrong control group to compare with neonatal deaths at homebirth. Judith Lothian made an attempt to argue that is doesn't matter. Now Henci Goer tries to divert attention away from the issue by quoting a bunch of papers and the numbers in them. You can read it here if you would like.

This is my response:

Perhaps the lay people on this board will not understand your attempts to baffle and misdirect them, but I do. Other people might be confused or impressed by lots of citations and lots of numbers. However, all the citations and numbers you presented above have essentially nothing to do with the issue at hand.

Johnson and Daviss used the wrong group as a control. You have not denied this, nor could you, since it is obviously true. You cannot use a control group fished out of other people's out of date studies. Since their control group is wrong, their conclusions are wrong.

It is just that simple.

It was the wrong control group, wasn't it? Yes or no.

Labels: Henci Goer

posted by Amy Tuteur, MD @ 2:50 PM

Smear tactics

Smear tactics are a staple of modern politics, but they can be used in other areas as well. Henci Goer's recent article is an excellent example of classic smear tactics in action.

Smear tactics work by manipulating emotions. They DEPEND on the assumption that most people have neither the time nor the knowledge base to evaluate whether the smear is factually true. They DEPEND on the assumption that if you deliberately associate a person with a bad event, most people will have neither the time nor the knowledge base to evaluate whether that particular person was in any way associated with the bad event. They DEPEND on the assumption that if you "throw enough mud against the wall, some of it will stick".

The following paragraph is an excellent example of the fine art of the smear:

Gawande applauds doctors for trying whatever appeals to them without “wait[ing] for research trials to tell them if it was all right.” It is sufficient that obstetric innovators “looked to see if results improved,” although how they would know this without a controlled evaluation of safety and effectiveness, he does not say. Neither does he bring up the obstetric disasters that have followed in the wake of this approach. DES, thalidomide, retrolental fibroplasia (blindness in premature newborns), and misoprostol (Cytotec) inductions come to mind ...

Let's do what we're NOT supposed to do, let's analyze this sentence for factual accuracy to find out whether obstetricians really created these problems, and created them because they did not take the time to do controlled trials before instituting a new practice. Here's what we need to know: what do the terms mean? when did these events occur? were obstetricians responsible for promoting these practices? did obstetricians institute these practices without appropriate controlled trials?

I'll start with the easy ones first and save the hard one for last.

thalidomide

What is thalidomide? Thalidomide is a medication was used in Europe during the early 1960's. It was prescribed as a sedative. Thalidomide taken in the early weeks of pregnancy causes limb defects. Typically, the babies were born with flipper like appendages instead of fully developed arms.

When was thalidomide used? It was used in the early 1960's. No medications causing birth defects had ever been identified before. No one knew it could happen.

Was thalidomide use promoted by obstetricians? No. Furthermore, thalidomide was never used in the US. An official in the Food and Drug Administration refused to allow the drug to be used in the US because she had read the case reports in the European literature. As a result of the European experience, the FDA instituted studies to see if other medications could cause birth defects.

Bottom line: Thalidomide was never used by obstetricians and was never even allowed in this country.

Retrolental fibroplasia

What is retrolental fibroplasia? One of the leading causes of death of premature babies has always been immaturity of the lungs. Since they don't work properly, the baby cannot get enough oxygen from room air. Initially, this was treated with oxygen piped into incubators.

When did this occur? Oxygen supplementation for prematurity was instituted in the 1940's. Thousand of lives were saved by it. The side effect of blindness was noted almost immediately thereafter in the survivors. The hunt for the cause was on. It was not until the early 1950's that it was recognized that the cause was high concentrations of oxygen.

Did obstetricians use it? No, it was used by pediatricians to save premature babies.

Were controlled trials done? No, no one thought it was necessary to test oxygen before using it on premature babies.

Bottom line: Retrolental fibroplasia has nothing to do with obstetricians. I find it very difficult to blame pediatricians for this unexpected side effect, but if Henci Goer wants to do so, she can.

Cytotec

What is Cytotec? Cytotec is a prostaglandin. Since prostaglandins are known to stimulate readiness of the cervix for labor, it was used as part of inductions.

When did it happen? It has been used for the past 15 years or so.

Did obstetricians use it? Yes.

Were controlled trials done? Yes, they were. Studies showed Cytotec to be safe and effective. It wasn't until the drug was put into clinical practice that the affect of Cytotec on women with previous uterine incisions was noted. Those women were more likely to rupture the incision than women who didn't receive Cytotec. The same people who published the original studies showing the safety of Cytotec were the ones to publish the studies showing it wasn't safe for women with previous incisions.

Bottom line: Cytotec went through the process that Goer recommends and was found to be safe. It was only during widespread use that the side effect for a subgroup of women was found. The system worked exactly as Goer insists that it should work.

DES

What is it? It is a hormone that was thought to prevent miscarriages.

When was it used? From 1938-1971.

Did obstetricians use it? Yes.

Were clinical trials done? Trials were not done until the early 1950's and they showed the DES did not prevent miscarriages. Some obstetricians continued to prescribe it anyway because they wanted to be able to show women they were doing something to prevent threatened miscarriages. The FDA told physicians to stop prescribing it in 1971 after it became apparent that DES caused rare vaginal cancers in adult women who had been exposed to DES in utero.

Bottom line: DES was never shown to be effective in preventing miscarriage and should not have been used. No one anticipated that it could cause defects that wouldn't show up until adulthood; this was the first time that a defect was not noted until adulthood.

So, of the four side effects that Goer writes about in this sentence, two had nothing to do with obstetricians at all, and one was handled in exactly the way that Goer prescribes. Only DES stands as an object lesson in why new treatments must be tested before allowed into clinical practice.

There is one more component to the smear that must be addressed. DES has not been used for 35 years. Very few if any practicing obstetricians have ever prescribed it. Nontheless, Goer implies the following claim: if the predecessors of today's obstetricians were wrong, you cannot trust anything they say today.

In politics, smear tactics tell us more about the person who uses them, then about the person accused. It is the same thing here. Goer is so desperate to condemn obstetricians that she throws any "mud" that is available, whether it is true or not, hoping that some of it will stick. A smear is not an argument, though. It is merely a sign that her own argument is so weak that she needs disreputable tactics to bolster it.

Labels: Henci Goer

posted by Amy Tuteur, MD @ 7:13 AM

Normal Birth Forum

When I searched for a place to pose a question to Henci Goer, I found her on the "Normal Birth Forum" on the Lamaze website. The name of the forum is emblematic. In just three words, Lamaze managed to succintly capture the offensive stance of the natural childbirth and homebirth movements. The use of language is instructive and all too typical. The word "normal" is used to exclude, to demean, and, of course, to be self congratulatory.

Think about it. Can you imagine a website about raising children having a "Normal Children Forum"? Can you imagine a health website having a forum for "normal" people? Of course not. We immediately recognize the use of the word "normal" in these situations as offensive and deliberately so. It is no less offensive to imply that natural childbirth is the only form of "normal" birth, no matter how personally satisfying it is for natural childbirth advocates to cheerfully demean other women and to congratulate themselves.

Labels: "natural" childbirth, Henci Goer

posted by Amy Tuteur, MD @ 10:02 AM

There's no debate if the other side gives up

Well, no one can say that I am not trying to debate homebirth advocates.

I guess it's not surprising that I did not get very far in my attempt to draw Henci Goer into a debate. It can't be a true debate if one side will debate only if it is sure it can win.

Here's the end of Ms. Goer's most recent post to me:

"... To repeat the close of my first response, "We'll have to agree to disagree." Clearly you are not going to change my mind, and I am not going to change yours. Viewers can read what we both have written here and elsewhere and make up their own minds as to who has the more compelling arguments.."

Here's my response:

I'm sorry that you do not wish to engage in any further discussion. That suggests that you can't refute the arguments that I have made. Reluctance to engage in any debate about the other articles is not surprising, since it would quickly become apparent that most articles in support of homebirth and many articles that attempt to support natural childbirth are profoundly flawed. Indeed, no article to date shows homebirth to be as safe as hospital birth, regardless of what homebirth advocates continue to claim.

Homebirth advocates, in general, scrupulously avoid any debate with medical professionals. Medical professionals cannot be manipulated with faulty statistics, poorly contrived papers, and papers that make claims directly contradicted by their own evidence. Only lay people will fall for those tactics.

People who make scientifically defensible claims about obstetrics would have no hesitation in providing scientific evidence to support those claims, so other professionals can judge the various arguments on their merits. Unwillingness to present claims in a forum of medical and scientific professionals, the only people who can judge the veracity of those claims, indicates a fear of losing the debate.

Visitors to my website are constantly asking for a debate between a professional homebirth advocate and an obstetrician. I'd be happy to participate in such a debate on my website, or a neutral website, but I cannot find any professional homebirth advocates who are willing. Indeed, I cannot find any evidence that any professional homebirth advocate has presented his or her work to a scientific audience and taken questions in response. The unwillingness on the part of homebirth advocates to engage in a true scientific debate, a debate with others who have a command of the literature and a knowledge of statistics, speaks volumes about the quality of the claims; a large proportion of their claims are not defensible.

Labels: Henci Goer

posted by Amy Tuteur, MD @ 2:48 PM