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An Update on Water Immersion During Labor and Delivery

Science Based Medicine last covered the increasingly common practice of laboring while immersed in water, in many cases followed by delivering the baby while still submerged, a little over four years ago. In that post, Dr. Amy Tuteur focused primarily on the contamination of the water with a variety of potentially pathogenic bacteria and the associated risk of infection. She also touched on the some of the other risks of giving birth underwater and made some excellent arguments against many of the claims made by proponents. I recommend reading that post and the ensuing comments.

This week, a new joint clinical report from the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) on immersion in water during labor and delivery was published in both the April Pediatrics and on the ACOG website. The media has responded with the typical flurry of falsely dichotomous coverage, pitting maternal-fetal medicine experts against midwives and other waterbirth proponents and leaving it up to the reader to decide which side is right. This March 23rd, an NPR article by Nancy Shute is a particularly frustrating example of weak medical reporting. In the article she essentially portrays giving birth underwater as an established and safe practice and medical experts as overly focused on a few flimsy anecdotes and case reports:

“Case reports are the lowest form of evidence,” Shaw-Battista counters. She is completing a study of 1,200 women who labored or birthed in water, and says they did as well or better than women who did not. “Given the bulk of the data, I don’t think we should use case reports to reject options that women are currently enjoying.”


Like many proponents, Shaw-Battista, who is the director of the Nurse-Midwifery Education Program at UCSF, touts unpublished data and subjective claims. About the only thing she says in the article that I can’t argue with is that if a family is going to deliver underwater it should be “conducted with a trained professional, be planned, and follow established guidelines.” I may not support the practice, but there absolutely should be somebody present who knows to get the baby out of the water right away without causing an avulsion of the umbilical cord, to not put the baby back in what amounts to sewer water for any reason, and who can perform neonatal resuscitation if necessary. That’s more likely to happen when a waterbirth takes place at a hospital or birthing center, which many do, but is decidedly less likely to be the case during a home birth, many of which are attended by laypersons with little to no experience in dealing with complications of any kind.

In the article, Shute also significantly misrepresents a 2009 (updated a bit in 2011) Cochrane review of immersion in water in labor and birth, and not just by calling it a 2012 review, which is when it was made available online:

A 2012 Cochrane review found no harm to the baby in 12 randomized controlled trials of water labor or birth involving 3,243 women, and less use of epidural anesthesia.

Yes, the Cochrane review looked at 12 studies, but 9 of them only involved immersion during the first stage of labor, which ends upon complete cervical dilation. The AAP and ACOG aren’t too worried about the first stage of labor other than the possibility that sitting in a tub of water might possibly interfere with providing appropriate emergency medical care in the event of a complication. They also ask nicely that facilities providing water immersion during the first stage of labor to please keep the tubs clean, however.

They admit that there may be some benefit in that there appears to be a little, and I mean a little, less use of spinal/epidural analgesia and that progression to the second stage of labor (delivery of baby but not the placenta) might move a little faster. It is questionable how clinically significant these benefits are however. And there is absolutely no evidence whatsoever that water immersion improves outcomes related to the baby. Only three of the studies used in the Cochrane review looked at the actual delivery, and they were unable to draw any conclusions regarding safety and efficacy.

A fine example of complementary and alternative reality in regards to labor and delivery can be found at Waterbirth International, which is run by >Barbara Harper, a nurse who preaches the benefits of waterbirthing all over the world and who is a proud proponent of rebirthing-breathwork. Rebirthing-breathwork is the concept that suppressed negative emotions can be healed by reliving one’s birth…and breathing a lot. Also there is something in there about cells having feelings. Harper gets the last word in the NPR article:

“I think this is backlash from the gaining popularity of water birth,” says Barbara Harper, founder of Waterbirth International, an advocacy organization…One thing that happens in a water birth, you as the attending physician pretty much have to stand there with your hands in your pockets and let it happen without your participation. That is pretty scary to a physician-oriented institution.”

How’s that for a straw man? Medical experts are apparently only skeptical of waterbirth because we don’t get to participate, which I have little doubt is code for “we don’t like it cause we don’t get paid.” I wonder if she works for free.

I believe that most rational people, even those with no medical experience, intuitively understand that delivering a baby into a body of water, even a sterile one, would be inherently risky. Human newborns, as with all other primates (take that Discovery Institute) breathe almost immediately upon arrival into this world. This helps to initiate a chain of events that assists the neonate in transitioning from fetal to adult circulatory patterns, and there are millions of years of evolutionary momentum behind this process. But besides being a completely unnatural act, something that usually sends proponents of pseudoscience running, there are numerous potential risks involved with giving birth underwater.

Before I discuss the risks, however, allow me to pass along the proposed benefits so that you might make an informed risk-versus-benefit determination for yourself. The following information comes from a Waterbirth International FAQ on the subject and is fairly representative of what other organizations claim and of the degree of misinformation patients are subjected to. Here is another example of information supportive of waterbirthing available online that goes much further, even implying that premature infants and other babies at high risk of complications, such as large babies at risk of becoming stuck at the shoulders during delivery, are good candidates. There is also a reference to the “aquatic ape” hypothesis hidden in there.

The most common proposed benefit of water labor and birth is less pain, and therefore a better chance of achieving a “natural” childbirth without drugs for maternal comfort. This desire for a drug-free childbirth is based on the naturalistic fallacy, misleading claims of risk by proponents, a large helping of misogyny, and dubious ethics on the part of medical professionals who would otherwise never allow a patient to suffer. Other more objective claims are that it speeds up labor, decreases the need for C-sections, and reduces the number of trauma-requiring interventions. Proponents also claim that decreased maternal stress hormones are better for the baby, and that the newborn transition will be gentler which just has to be a good thing. The rest are entirely subjective, such as increased relaxation, improved sense of well-being and control, or involve how satisfied the mother was with the process.

So what kind of evidence base supports these claims of benefit? According to the recent statement from the AAP and ACOG, and I’m paraphrasing a bit, it ain’t good. The following quote works too:

Most published articles that recommend underwater births are retrospective reviews of a single center experience, observational studies using historical controls, or personal opinions and testimonials, often in publications that are not peer reviewed.

The authors also point out that there is a complete absence of any basic science, in either animals or humans, to support the proposed physiologic benefits of giving birth to a human underwater. Plenty for fish though.

Another huge problem with the evidence for water labor and birthing, whether published in peer reviewed journals or anecdotes on websites and documentaries, is the lack of consistent definitions. What defines water labor and waterbirth varies from situation to situation and between institutions. Timing, temperature, maternal health problems and location can vary significantly. And I’ve already given you an example of a so-called science reporter conflating safety data from just labor with safety of underwater birth, which is at the very least extremely misleading, and potentially dangerous. There is also a complete lack of blinding and virtually no controlling for the other aspects of the birthing environment when comparing standard to underwater deliveries.

What does the available evidence support after taking into account the poor quality of available data? Not a whole lot. As I stated earlier, there appears to be a modest, though perhaps not clinically significant, decrease in the use of pain-reducing procedures. There also appears to be a decrease of about half an hour in the time it takes for labor to progress to full dilation, but again this is hampered by a lack of controlling for potential confounders. There is no good data to support a difference in delivery-associated trauma, the need for vacuum or forceps assistance, or the need for a C-section. There is no evidence to support claims of benefit to the newborn. But it does seems that mothers are more satisfied with delivery underwater, which may only be a result of theatrical placebo employed by waterbirth attendants.

Now that I hope I’ve made it clear just how flimsy the case for giving birth underwater is, it is time to discuss the potential risks. Similar to the data held up by proponents as supportive of their claims of benefit, the risk of underwater birth is largely based on individual case reports and series, although the basic science foundation is solid. This means I can’t tell you how common it is for these complications to arise, but of course the burden of proof does fall on the proponents to show benefit. That being said, the risks that have been reported can be quite serious, even deadly. I’ll just list them:

  1. Increased risk of infection, especially after rupture of the membranes acting as a barrier between baby and the outside world
  2. Problems with temperature regulation in the baby
  3. Damage to the umbilical cord, or pulling of the cord out of the placenta, leading to severe bleeding complications
  4. Respiratory distress, hyponatremia, seizures and asphyxia from fresh water drowning

These risks, although rare, are potentially catastrophic. There are numerous case reports/series of deaths and significant morbidity. One study that was not included in the Cochrane review because it involved a comparison of standard delivery and waterbirth of infants with dystocia (abnormal or difficult childbirth/labor) showed that 12% of the babies born underwater required NICU admission while none of the babies born dry, relatively speaking, did. The only variable in a delivery that can lead to fresh water drowning, for instance, is the choice to have a waterbirth. That alone, in my opinion, is enough to establish that at this time the risk outweighs the benefit. The incidence of these adverse outcomes is likely much higher when an infant with risk factors is born underwater. Essentially the same issues that come up with home births in general are exacerbated by adding water.

Why don’t babies breathe when they are born underwater? According to Barbara Harper, there are many reasons, including that God doesn’t want them to, but four that stand out:

1. Prostaglandin E2 levels from the placenta which cause a slowing down or stopping of the fetal breathing movements. When the baby is born and the Prostaglandin level is still high, the baby’s muscles for breathing simply don’t work, thus engaging the first inhibitory response.

Healthy babies born without difficulty typically breathe within ten seconds of birth, but many breathe right away. The likely reason that there isn’t a higher incidence of aspiration of water after delivery is that the standard approach is for the attendant to remove the baby from the water right away, though with care to not damage the umbilical cord. A sick baby may have already begun gasping breaths while still in the womb, and they often pass stool prior to delivery which can be aspirated and cause a great deal of morbidity and mortality. If a sick baby were to be born into water, they are almost certainly at increased risk of drowning.

2. All babies are born experiencing mild hypoxia or lack of oxygen. Hypoxia causes apnea and swallowing, not breathing or gasping.

This demonstrates a complete misunderstanding of newborn physiology around the time of birth. Yes, oxygen saturation levels in newborn babies are not 100%. They slowly rise over the first several minutes of life to normal levels. So this is true in that sense. In regards to apnea, I can only assume that she means primary apnea. This occurs when an infant is unable to achieve adequate oxygenation through breathing once the placental supply of oxygen is diminished. It is never normal for a newborn to be apneic, but it is somewhat common.

Primary apnea, when it occurs, often responds to simple stimulation to breathe as occurs during drying and providing a clear airway, while secondary apnea, which occurs after a prolonged lack of oxygen delivery to the brain, requires more aggressive resuscitation. Again, babies typically breathe within a few seconds of birth. So the attendant at a water delivery must quickly retrieve them from the water. I’m sure they make it seem like a gentle and loving thing, but as soon as the kid hits the water, the clock is ticking and such a nonchalant reference to apneic newborns is frightening.

3. Fetal lungs are already filled with fluid. That fluid is there to protect the lungs, and keep the spaces open that will eventually exchange carbon dioxide and oxygen. It is very difficult, if not improbable, for fluids from the birth tub to pass into those spaces that are already filled with fluid. One physiologist states that “the viscosity of the fluid naturally occurring in the lungs is so thick that it would be nearly impossible for any other fluids to enter.

This is true, prenatally. But the onset of labor signals a surge of chemicals called catecholamines that signal the lungs to quickly reabsorb fluid. This is why babies that are born without labor, such as via a scheduled C-section, often have a transient period of fast breathing related to some retained fluid in the lungs. The lungs are not “filled with fluid” at the time of delivery however, and will readily accept a bolus of fresh water as has been reported many times. In fact, premature infants, and sometimes even those delivered at term, often have medicines purposefully squirted into the lungs via an endotrachial tube right after birth. They get in there just fine.

4. The last important inhibitory factor is the Dive Reflex and revolves around the larynx. The larynx is covered all over with chemoreceptors or taste buds. The larynx has five times as many as [sic] taste buds as the whole surface of the tongue. So, when a solution hits the back of the throat, passing the larynx, the taste buds interprets [sic] what substance it is and the glottis automatically closes and the solution is then swallowed, not inhaled.

The dive reflex occurs in aquatic mammals primarily but there is a weaker version in humans. It involves a reduction in heart rate and a shunting of blood from the peripheral vasculature to the vital organs, primarily the heart and brain, allowing for an extended duration of breath holding. This reduction in heart rate can actually sometimes be put to medical use in young patients presenting with one type of arrhythmia called supraventricular tachycardia. We hold a bag of ice water over the entirety of their face. Strange but true.

The dive reflex only occurs when the face is submerged in very cold water. Breath holding associated with submersion in cold water is an involuntary process where breathing is centrally inhibited. What waterbirth proponents are confusing the dive reflex with here is drowning. During drowning, when water hits the airway there is spasm of the surrounding musculature and closure of the epiglottis. This prevents aspiration and forces swallowing of the water, which is why there is risk of hyponatremia in fresh water drowning. Eventually the spasm will relax and water will be taken into the lungs.

These are the people delivering our babies. When waterbirths take place in cold water, which they never do because that would interfere with the pleasurable experience of the mother, they can talk about the diving reflex. Or if they are delivering a seal. You know what really interferes with the pleasurable experience of the mother? A dead baby.

One final time, the reason why more babies don’t tend to aspirate water after a waterbirth is timing and luck. They are retrieved prior to the first breath, which may be a little delayed because of reduced stimulation to a baby born underwater. It is as simple as that. Some babies will always breathe too soon. Sick babies are more likely to breathe too soon. If a baby develops primary apnea, and stimulation to breathe is delayed because they are underwater, their heart rate will plummet and prolonged lack of oxygen to the brain will lead to them requiring substantial resuscitation.

Final thoughts

The conclusion of the AAP/ACOG statement that has waterbirth proponents so bent out of shape is extremely well-reasoned. They admit that water immersion during the first stage of labor might have some very limited benefit as discussed above. But they stress that there isn’t evidence to support improved perinatal outcomes, and that if a mother chooses to relax in a pool filled with water it shouldn’t get in the way of other aspects of appropriate care. Of course lay midwives attending a home waterbirth might have a different opinion regarding what those are.

In regards to actually delivering in the water, the authors conclude that the safety and efficacy is not established. They state, based on the many case reports of severe complications and lack of quality evidence to support maternal or fetal benefit, that any underwater deliveries should be considered an experimental procedure and take place in the context of a clinical trial with informed consent. And there is the rub. I have grave concerns that appropriate informed consent is currently not being obtained, that the benefits are overhyped and the risks downplayed beyond what is supported by the evidence. A lack of proper informed consent violates one of the four foundational principles of medical ethics, which is a respect for the patient’s personal autonomy.

There are few things as intimate and emotionally powerful as the process of giving birth. The variables inherent in this process range from the fairly minor, such as what music a mother would like to listen to during labor, to the extremely important choices of where and how the baby is to be born and who is to be in attendance at the delivery. Many of these choices have relatively little if any impact on the health of the newborn baby or on the risk of maternal complications, but rather help to mold and shape the overall experience of childbirth to the mother’s liking. Regardless of the importance of each choice, it should come as no surprise that they are as subject to personal biases, logical fallacies, and social and cultural influences as any other decision.

Expectant mothers, and often their families, put a great deal of focus on the subjective experience of childbirth, and this is understandable as the memories being forged will last a lifetime. There is unfortunately, for many families, an idealized perfect labor and delivery experience that often appears to be based more on television and movie portrayals or the anecdotes of friends than on explanations by science-based healthcare professionals. But sometimes this ideal experience is molded and shaped by biased healthcare professionals employing motivated reasoning, or by nonprofessional lay practitioners who hold themselves up as birthing experts.

They all likely mean well and want what is best for the mother and baby, but that is not an excuse. Childbirth is a time of great vulnerability. All parents want their children to enter the world happy and healthy, and to stay that way as they grow. Unfortunately, when this all-too-human desire to have a positive birth experience and a healthy baby is hijacked by excessive worry based on false or misleading information, people can make uninformed and potentially deadly decisions. My provisional conclusion is that choosing to deliver a baby underwater is such a decision. If proponents are at some point able to present good evidence to show that the benefit of waterbirth outweighs the risk, I will gladly change my opinion.

-Here is a nice discussion published in Pediatrics in 2004, titled “Water Births: A Naked Emperor.” Here is the midwife response and subsequent destruction of that response by Dr. Schroeter.

-Dr. Jen Gunter, an evidence-based OB/GYN and pain medicine physician, also recently discussed the AAP/ACOG statement on her website. She agrees that introducing water to the birthing mix shouldn’t get a free ride.

-Finally, here is a satirical look at the extremes people go to in an effort to have a memorable birthing experience.

Posted in: Obstetrics & gynecology

Leave a Comment (133) ↓

133 thoughts on “An Update on Water Immersion During Labor and Delivery

  1. windriven says:

    ” there appears to be a little, and I mean a little, less use of spinal/epidural analgesia”

    One presumes there must be a phalanx of burly orderlies standing by to haul the gravid, slippery, paralyzed woman from the tank in the event of medical emergency. Further, women sometimes poop during labor. The notion of immersing a catheter leading into the epidural space in a slurry of e coli strikes me as , what, stupid?

    “Rebirthing-breathwork is the concept that suppressed negative emotions can be healed by reliving one’s birth…and breathing a lot.”

    Yes, breathing a lot is a wonderful thing. But rebirthing? Really? I’m struggling to imagine a more humiliating and pointless activity. Preliving one’s death perhaps. Or performing the Rach 3 for a live audience on a kazoo.

    But here Dr. Jones and I part company:

    “This desire for a drug-free childbirth is based on the naturalistic fallacy, misleading claims of risk by proponents, a large helping of misogyny, and dubious ethics on the part of medical professionals who would otherwise never allow a patient to suffer. Other more objective claims are that it speeds up labor, decreases the need for C-sections, and reduces the number of trauma-requiring interventions. Proponents also claim that decreased maternal stress hormones are better for the baby, and that the newborn transition will be gentler which just has to be a good thing. The rest are entirely subjective, such as increased relaxation, improved sense of well-being and control, or involve how satisfied the mother was with the process.”

    Starting with the last, absent compelling evidence of elevated risk (and we are talking now about a drug-free childbirth, not giving birth in a pail of water) to mother or child, actions promoting maternal satisfaction seem to me a pretty frigging important objective. One of the medical attitudes that pushes people to sCAMmery is apparent indifference to patient satisfaction. Equally important are the “objective claims” of decreasing C-sections. And I am totally at a loss to imagine how misogyny fits into a mother’s wish – as silly as it may seem – to want to avoid an epidural.

    1. Durango says:

      The misogyny part is the belief that women *should* suffer the pain of childbirth, that only wimps get an epidural. Surf the web, if you will, and see the accounts of women who feel like they “failed” or “caved” in to the overwhelming pain of childbirth and got an epidural. There is no other painful (healthcare) process that has the expectation that one will go without pain medication. No one thinks a root canal done with anesthetic is deserving of praise. If a women wants to go without pain meds, that is of course her right, but no one should be telling her that it’s the only real way to give birth.

      1. Durango says:

        *without* anesthetic

    2. Clay Jones says:

      Patient satisfaction is inherently influenced by a number of biases and errors in logic. The push to make patient satisfaction the primary means of evaluating physicians and hospitals is taking us down the wrong path as it actually decreases the quality of care. That being said, I agree with you that how happy a mother is with her birth, and her wishes for how that birth should go, is important. My point is that there is an assumption that because a mother states she was happy with a water birth, or a drug free birth for that matter, it must be that specific variable that made the difference. Perhaps if a mother got all the trappings of a water delivery, but just didn’t actually have the waterbirth, she would be just as happy. We don’t know because the studies aren’t well controlled and certainly aren’t blinded. How could they be blinded?

      Just because a mother wants something, whether it is a waterbirth or a prescription for antibiotics, doesn’t justify doing it. Physicians, despite the recent trends, are not simply service providers who must follow the “customer is always right” dictum. Waterbirth is, like Dr. Gunter wrote in the post I linked to at the end, an intervention. We just came up with it. It should be supported with evidence.

      In regards to a drug free childbirth, read Dr. Hall’s linked to post on the subject for a good discussion.

      1. David Gorski says:

        The push to make patient satisfaction the primary means of evaluating physicians and hospitals is taking us down the wrong path as it actually decreases the quality of care.

        Indeed. At the very best there is no correlation between patient satisfaction and quality of care. At the very worst, there is a negative correlation between patient satisfaction and quality of care.

        http://www.sciencebasedmedicine.org/keeping-the-customer-satisfied

        1. windriven says:

          @Drs. Jones and Gorski

          “The push to make patient satisfaction the primary means of evaluating physicians and hospitals is taking us down the wrong path as it actually decreases the quality of care. ”

          A straw man. An arrogant misstatement of what I said. I’ve read and reread my comment and I neither stated nor implied that patient satisfaction should be the primary means of evaluating anything or anyone. What I said quite clearly is that absent compelling evidence of elevated risk (and we are talking now about a drug-free childbirth, not giving birth in a pail of water) to mother or child, maternal satisfaction should be an important objective. There is nothing in that statement suggesting actions that would compromise quality of care.

          “At the very best there is no correlation between patient satisfaction and quality of care.”

          So what is the quality of care when the patient, sensing the physician’s indifference to her satisfaction, goes instead to her neighborhood doula? Is that the desired outcome for science based medicine???

          The issue of satisfactory physician interaction is one that commenters raise with some regularity in these pages. It doesn’t mean ‘the customer is always right.’ But ignoring it, poo-poo-ing it, and talking around it doesn’t make it less of an issue for the people choosing providers and paying the bills.

          1. irenegoodnight says:

            I totally agree with you WD. I never wanted epidurals and I am far from the type of person Dr. Jones describes. I hope I will not be mistaken for a crazed hippie when I say that I think childbirth (under normal circumstances) is an experience, not a medical problem. Women should experience it the way they wish without judgment–kind of like breastfeeding–or not.

            1. Young CC Prof says:

              I am definitely fed up with the natural child birth movement. However, it is absolutely none of anyone else’s business whether you chose to use pain relief, or not, or why you made your choice either way. Your body, your choice. (The only situation that would bother me is the one in which you asked for pain relief and didn’t get any, since that’s substandard medical care.)

              The problem is when folks start condemning women who do use pain relief, or, more seriously, when folks encourage pregnant women to question, resist, delay and even flat-out refuse medically necessary interventions, or try to tell women that the treatments usually do more harm than good.

              Or, of course, insist that practices like water birth present zero risk to the baby. Before the new ACOG report was released, the top several google hits for water birth insisted that there was no risk at all, no way it could cause infection, or that the baby could breathe it in.

              When the lies are that entrenched, how can women make rational choices?

              1. Clay Jones says:

                It isn’t that black and white however. Childbirth can be incredibly painful, and there is not evidence to show that appropriate pain reducing measures are harmful. Obviously pain is subjective and some folks can certainly tolerate levels that others can’t. But many women require proper pain control once delivery is in full swing, which is problematic. Furthermore, not providing pain control is not an option for any other medical procedure that can cause severe pain. At least it isn’t ethical to do so. I realize it happens, and have even written about it, with some procedures like circumcision or drainage of a small abscess. But reducing a fracture without pain meds?

            2. windriven says:

              “I never wanted epidurals and I am far from the type of person Dr. Jones describes.”

              I’m the father of 4 kids and I never had an epidural either ;-)

              My then wife didn’t either, though I never understood why. Two of my daughters have now had babies and both eschewed epidurals. Beats me why but absent a compelling reason to have one, I was ill-disposed to make an issue of it for any of them.

            3. Calli Arcale says:

              Irene — I would agree that childbirth is a normal process and not a medical problem. However, there are quite a lot of very serious medical problems which can start to happen extremely quickly during that process, and I think that’s maybe the approach that needs to be taken. Childbirth isn’t a disease, and if all goes well you won’t need interventions, but it’s good to be ready in case all does not go well.

              And honestly, it’s okay to use pain meds. It doesn’t make you less of a woman. Women all over take a variety of drugs, both regulated and otherwise, to help with menstrual pain; so why not childbirth? It doesn’t *have* to hurt, and anesthesia really has come a very long ways. I guess what I’m trying to say is there are choices, and that is a good thing. ;-)

          2. Clay Jones says:

            You left out my first sentence: “Patient satisfaction is inherently influenced by a number of biases and errors in logic.”

            Anyway, arrogant? Please. You are being naive if you think that the only thing that matters is evidence of significant risk. The appropriate treatment of pain is an ethical imperative. Ethically not treating pain is no different than causing pain intentionally. There would have to be significant evidence of benefit to make it a reasonable thing to do. I wouldn’t argue that women should have pain medications forced into their spines, for instance, but there should be a much greater effort by medical professionals to educate mothers about the reality of so-called natural child birth.

            1. windriven says:

              “Anyway, arrogant? Please.”

              Absolutely arrogant. It totally mischaracterized my statement. If the roles were reversed and a commenter here pulled a straw man of that blatancy there would have been an eruption of indignation.

              “The appropriate treatment of pain is an ethical imperative.”

              Despite the patient’s wishes? That strikes me as an ethically tenuous position. One might mount that argument following major thoracic surgery in the interest of promoting deep breathing to keep lungs clear.

              1. Clay Jones says:

                Couldn’t I have simply been mistaken? Misread what you wrote or interpreted it based on the bias that has crept in after researching and writing about the mindset of proponents of pseudoscience for over a decade?

                Again, you left out my first sentence which was the response to your comment specifically. My general comment on the use of patient satisfaction to grade physicians and hospitals was both accurate and not intended to specifically address your point about natural childbirth, although there is overlap, which was the point of my additional response about the ethics of treating pain.

                Ideally in medicine we convince the patient or, as is the much more common case for a pediatrician such as myself, the parent to accept appropriate pain control. If a parent, afraid of opioids for some reason, refused the use of morphine for their child whose leg was snapped in half I would do my best to make them understand the situation and consent. If push came to shove, I could take the step of raising the issue of medical neglect. Again, not treating that child’s pain is absolutely no different than taking a well child and inflicting pain on them.

                For an adult who really just won’t consent to proper pain control, as I said above I wouldn’t recommend forcing an IV in their vein and doing it anyway. I would do my best to educate and hopefully they would consent. For childbirth, the baby has to be born, right? I don’t think that an OB who takes part in a natural childbirth is being unethical, as long as they attempted to educate. But I question the ethics of any practitioner who actively promotes and encourages it because, again, there is no evidence of benefit other than patient satisfaction which I feel is not good enough.

              2. windriven says:

                “Couldn’t I have simply been mistaken? Misread what you wrote or interpreted it based on the bias that has crept in after researching and writing about the mindset of proponents of pseudoscience for over a decade?”

                Yup. And if that is the case I owe you an apology. It certainly didn’t read that way.

                ” But I question the ethics of any practitioner who actively promotes and encourages it because, again, there is no evidence of benefit other than patient satisfaction which I feel is not good enough.”

                Every medical intervention carries risks. Poking a needle and introducing a catheter into the epidural space is invasive though generally pretty safe. But while rare, there are adverse effects ranging from headache to hematomas to meningitis to death.

              3. WilliamLawrenceUtridge says:

                Every medical intervention carries risks. Poking a needle and introducing a catheter into the epidural space is invasive though generally pretty safe. But while rare, there are adverse effects ranging from headache to hematomas to meningitis to death.

                Meanwhile thrashing about due to extreme pain while giving birth or having to conduct a medical procedure presents little risk?

                I’m not a woman, so I’ll never understand the desire to “experience” unnecessary birth pain. I’ll never understand how it is, or is supposed to be, different from any other type of pain. I’ll never understand the rhetoric behind it, nor the reasoning. For centuries people endured the setting of bones and sewing shut of wounds without anaesthetics or analgesics, now their use is routine and refusal to give them to a patient is medical misconduct.

                But birth is different?

                I realize Windriven, that you are more defending the right to refuse such medications if not desired. I suppose my gaster is flabbered at the desire and I can’t really get past that. And I’ll never even pretend to respect someone’s decision.

                Man, the world is lucky I’m not a doctor. I’d have the bedside manner of House, and the medical skill of Doug Murphy.

              4. windriven says:

                @WLU

                “Meanwhile thrashing about due to extreme pain while giving birth or having to conduct a medical procedure presents little risk?”

                If the risk is great it is under-reported in the literature. Also, the pain manifests not so much in thrashing as in a stream of profanity-laden invective damning me for implanting her with this alien succubus and assuring that no erectile tissue will be allowed near her va-jay-jay for the rest of her natural life.

                But look, I agree. I don’t understand the impulse to avoid the epidural either. But for some of the women in my life – smart, scientifically literate, thoughtful women, it was a choice they made.

              5. mouse says:

                Windriven “If the risk is great it is under-reported in the literature. Also, the pain manifests not so much in thrashing as in a stream of profanity-laden invective damning me for implanting her with this alien succubus and assuring that no erectile tissue will be allowed near her va-jay-jay for the rest of her natural life.”

                I remember my mom talking about my birth. I was born in 1965 and I’m under the impression that no epidural was available. My mom was in labor with me for about 23/24 hours, because I was positioned with my head wrong, they kept having to check my position, then ask my mother to hold her knees and rock backward and forward to try to get me to change positions. My mother, who was seldom expressed annoyance with folks, did express considerable annoyance with the nurse (to me afterwards)- who kept telling her “come on Mrs. ____ It’s time to rock the baby” – in a sing song voice. She figured if she was going to be in that much pain for childbirth, she shouldn’t be spoken to like a child. Finally I was born, with my head in the wrong position, maybe a bit short of oxygen – but it appeared I was probably okay…I think my mom held her breath for 7 years until I learned to read, then figured- good enough.

                Anyway – one reason I tell this rambling story is that my dad, who wasn’t allowed in the pre-delivery or delivery room, regardless, was home with a migraine (no drugs for that either, except aspirin) with my four siblings. I don’t think my mom had a family member at the hospital.

                So not only was my mom not thrashing about – she was actively engaged in doing the right thing for the delivery, she was politely putting up with an annoying person, with no husband to yell at.

                Which is not to say that anybody SHOULD put up with all that, anymore than they should put up with a migraine if they get a benefit from medication, but I just kinda felt my mother rolling her eyes at the thrashing comment and had to say something -lest I hear about it in the afterlife.

              6. brewandferment says:

                Everytime I try to explain my reasons for wanting an unmedicated labor and delivery I somehow make it come out wrong but I’ll try again.

                It isn’t about being competitive or being more a woman whatever that means (since I have the ladyparts and a kid in them that’s sufficient right?) or even trying to be tough. My personal choice to avoid a medicated labor really comes down to the fact that FOR ME an epidural was a greater evil than what turned out for me to be not terribly bad pain, certainly no more so than when I hiked over a pass in the Annapurnas of Nepal sans supplemental oxygen. (but not carrying a full pack!) And I’ve said before that even though I was fully aware that the needle is actually not in my spinal cord, just the thought of it being nearby was bad enough for me, as irrational as that may be. Intellectually I can understand that it’s usually pretty low risk but that does nothing for the personal phobia I appear to have with needles near my spine.

                On top of the phobia, there’s the mobility restrictions that were an even more obnoxious factor for me. I don’t like catheterization and ambulatory epidurals were not available to me with any of my kids, even if they’d all been hospital births. I recently enjoyed the benefits of a nerve block for ankle reconstruction surgery, but I can say even more adamantly that the numbness and lumpen feeling of this thing hanging off my hip was gross and I would have really hated that sensation in labor and delivery. I don’t sit still easily and was a pretty active person in labor so anything that would have interfered with that was bad.

                Last of all, just as you use muscle exhaustion and soreness as a gauge in weightlifting progress: do I add one more rep, if there is no soreness it’s time to add weight next time, for ME the sensations of labor and delivery were cues and aids in the job of bringing forth this baby and I didn’t want stuff that interfered.

                Bottom line: medical options for pain control were not satisfactory alternatives to dealing with it using the skills and tools (soaking in warm water, backrubs, etc) I already possessed. And most importantly with my 2 younger kids, I never needed anything more. If I had had, for example, a way more painful labor than the first kid, or a “sunnyside up” presentation with really bad back labor I would likely have requested a transfer to the hospital and my midwife would have cheerfully accompanied me.

                But I didn’t. I’m not better than someone who didn’t or couldn’t make those choices, and I’m not superior to them because I “toughed it out”–it really wasn’t that bad FOR ME.

                And I didn’t cuss out my husband either, although I did comment that “the little sh!t kicked me” as I was pushing out kid # 2…whether it was really the baby or just some funny cramp I dunno, it was more the surprise of the sudden sensation.

        2. Dave says:

          I beg to differ a bit. It depends on what you means by “patient satisfaction”. Such things as getting put on phone hold, not having calls returned, waiting half an hour to get a nurse to answer a call light, are legitimate concerns. Unfortunately it is often the doctor or nurse who takes the brunt of this dissatisfaction when it is an administrator who didn’t hire enough receptionists, clerks or nurses who is responsible. Patients should not be treated rudely, etc. (They also should not treat the health care workers rudely. I’m amazed at what nurses put up with sometimes. A good topic would be the level of assaults and threats against health care workers.) As far as birthing, anything to make the mother comfortable would be good as long as it doesn’t conflict with the primary goals of a healthy baby and healthy mother. There is literally NOTHING in the world more precious than that baby. I don’t understand how a mother could jeopardize the health of the infant for a better “experience”, and I’m sure most mothers wouldn’t.

          Having said that, the most common cause of patient dissatisfaction I’ve seen is the doctor refusing to supply narcotics for conditions that don’t require narcotics. Sometimes what the patient wants and what is good medical practice are in conflict. I pity emergency room doctors who have to deal with drug seekers all the time, and get poor Press-Ganey scores if they do what they think is right. I also feel sorry for the patients who truly need pain meds – their lives are made much worse by the drug abusers.

          1. windriven says:

            “It depends on what you means by “patient satisfaction”. ”

            Dave, it all boils down to how you look at health care consumption and delivery. The consumers that I have met and many of those who have raised the issue in these pages are not at all the sort who are seeking “narcotics for conditions that don’t require narcotics.” They are looking for a collaborative health care experience where they are told what is going on, understand therapy options, and participate in the management of their health. I certainly have that relationship with my internist. But I also had to go through a long, expensive and irritating search to find her.

            To talk about telephone hold times and pissy receptionists is to trivialize the issue. Every business should be managed well and customer service personal should be trained and fit for their jobs. But that, I don’t believe, is what drives patient dissatisfaction.

            Our focus on SBM seems sometimes to lead us away from the actual point of health care. Nobody lives forever. The point is quality of life for the longest reasonable span. Part of quality of life is not being left frightened, ignorant, or with little sense of control over one’s own destiny.

            1. weing says:

              I find that patient satisfaction depends on how long they have to wait in the waiting room before they get seen by me

              1. windriven says:

                Physicians’ time is valuable. So is patient time. With my New Orleans internist I would arrange first appointment of the day. Obviously, not everyone can have the first appointment but it worked for me. My current internist has never, so far as I can recall, kept me waiting more than a few minutes.

                Speaking only for myself, I understand the exegencies of medical practice and waiting for half an hour past appointment time is understandable – occasionally. But when it happens every time it suggests either a systemic problem with the office help or a distinct lack of give-a-sh!t.

              2. mouse says:

                That’s funny – I find that the longer I have been waiting to see a doctor the more likely it seems that they will be abrupt, surly, sarcastic or there will be an error in the paperwork*.

                I wonder if there’s any connection.

            2. mouse says:

              I think you make an excellent point here. Things that bother me are not things like being put on hold too long. It’s things like doctor’s offices not returning repeated requests for important test results. Conflicting pre-procedure directions. Leaving tests off the lab slip, The nurse that forgot to write down the abnormal result on my daughter’s TB test, so it had to be redone.

              Heck, awhile back I waited two hours for an appointment for abdominal pain (I had to find a sitter to watch the kids) at a doctor in my network who had walk-in appointments – then the doctor basically told me that I had too many previous tests, they didn’t have time to look through it all* because they had a meeting in a few minutes, ordered an x-ray to check for broken ribs(?) and prescribed muscle relaxants. Without really telling me why. I felt pretty demoralized. And I think, you know, it’s not a bad idea to avoid that doctor in the future. Call me shallow and trivial. ;)

              So – I’m fine with the idea that patient satisfaction shouldn’t be the ONLY consideration, but I would think it should be A consideration.

              *This is what happens when you have an ANA of 1280, then have abnormal kidney values and slightly low complements- doctors order a sh*&t load of test. It’s not actually my plot to annoy random doctors who get stuck with me.

              1. Dave says:

                If I were you I’d find another doctor. You raise a good point that there are more serious concerns than not returning phone calls. If you look at my post I was replying to this remark:

                “Indeed. At the very best there is no correlation between patient satisfaction and quality of care. At the very worst, there is a negative correlation between patient satisfaction and quality of care.”

                I was making the point that patients have legitimate concerns.

              2. mouse says:

                “I was making the point that patients have legitimate concerns.”

                I did get that – but I also kinda got the impression that you thought most of the concerns were clerical, administrative. I DID kinda go off there, though. Overall I thought you had some excellent points.

                I didn’t go back to that last doctor or group, by the way. :) But even setting that aside, if many of her other patients have similar experiences, I think that insurance companies may have a valid reason for wanting to examine her approach. Or maybe she just was having an awful day, I was the last straw and few other patients have had that experience.

          2. David Gorski says:

            Another really common complaint form patients that factor into patient satisfaction scores is—and I’m not kidding—the availability of parking or whether or not patients have to pay to park. Seriously, that gets lumped in with whether the patient thinks the doctor fulfilled his medical need for the visit.

            1. mouse says:

              Well – isn’t there some way to measure the things that we would consider valid quality of life patient concerns and separate them from other – say luxury concerns? This all seems a bit black and white.

              I have to say – completely separate from how I rate my doctors. I used to take my son for speech therapy once a week at a semi-local hospital In addition to the drive time, I had to leave about 45 minutes for parking and walking to the appointment, another 30 minutes for leaving the hospital/parking structure. This is not the end of the world, but if one is attempting to make life easier on kids who need regular therapy/medical care (or their families) then better parking is something to consider.

              On the other hand. I have discussed this hospital with many other families and people are always giving it good recommendations. I have never heard. ‘Well the medical care is great! But don’t go there because the parking sucks.”

              Maybe there’s something wrong with the forms.

      2. WilliamLawrenceUtridge says:

        Any outcome measure or measures for birth that don’t put maternal and infant survival at the very top is absurd as far as I am concerned.

        And I wonder about the self-selection for studies like this – what happens if you factor out those who wanted a waterbirth in the first place, then were unsatisfied when they had to be moved out of the blood toilet because of emergency care?

        Water birthing just seems like stunt birthing in my mind, an unnecessary and dangerous accretion on medicine as a result of speculative nonsense.

    3. WilliamLawrenceUtridge says:

      “Patient satisfaction” with birth in many ways, in modern times, at least for the wealthy, middle-to-upper class white folks who support a lot of parenting woo and nonsense, means “pain-free, competitive birthing without drugs or inducement, through the vagina only, ideally with the baby breastfeeding quickly and easily immediately afterwards”. That’s my Skeptical OB-informed assessment anyway. The “satisfaction” isn’t “I’m very satisfied that I have a healthy baby and didn’t die in the process”, it’s “I’m dissatisfied that giving birth was painful and I wasn’t able to tolerate it, and it didn’t meet my unrealistic expectations in the first place. Oh, and breastfeeding is hard and makes my nipples look like raw sausage.”

      My guess is that the “dissatisfaction” is similar to CAM-promoters dissatisfaction with real medicine; it’s dissatisfaction that real medicine is nuanced, sub-optimal, includes adverse effects and risks, can’t explain all things, and can’t give absolute certainty. It is the dissatisfaction of a complex reality compared to unrealistic expectations.

      I could be wrong, but that’s how I interpret what I’ve read.

      1. mouse says:

        It’s funny I have a close family member who works in OB anesthesia and her opinion of patient satisfaction in white middle class women seems to be completely different than the Skeptical OB (does anyone else remember Dr Tuteur’s brief but fiery interlude here on SBM?)

        Her summary seems to be “I like working OB because the women are usually so happy to see me”

        I wonder if Dr. Tutuer’ focus on home birth and alternative medicine might be giving her a bit of selection bias in judging the attitudes of “white upper/middle class women” today.

        1. windriven says:

          “does anyone else remember Dr Tuteur’s brief but fiery interlude here on SBM?”

          That was a train wreck!

        2. WilliamLawrenceUtridge says:

          But as an OB anaesthesiologist, she would also tend to not see the women who approach childbirth as a competitive sport rather than a medical event. They wouldn’t ask for anaesthesia, often until the pain is too great to bear (at which point labour has progressed too far for the anaesthesiologist to be involved). This would also be selection bias. Plus, while there may be many, many more white upper/middle class white women who don’t favour stunt birthing, there are enough of the small percentage who do to ensure tens of thousands of such births every year in t US. We face something similar in the number of pro-CAM loons who show up here – we get a deranged self-selected slice of opinions because we criticize their sacred cows.

          1. mouse says:

            @WLU She’s an Anesthetist – also even if she doesn’t see some women who decline epidurals. She does see those women if they end up needing c-sections. Also she see the home birth patients who get sent to the hospital due to problems.

            “We face something similar in the number of pro-CAM loons who show up here – we get a deranged self-selected slice of opinions because we criticize their sacred cows.”

            Yes we do. Which is why I think it’s important not to make vague and negative generalization about what “patient satisfaction” means based on observations of the most strident and fringe individuals at their very worst (online behavior is always the worst behavior).

            I mean it just sounds a bit like “Well mothers who want a nice* birth experience don’t really care about their babies. They care more about the mommy competition.” When we’ve established that many mothers are being given misinformation about the risks and benefits of this “experience.” So maybe portraying the women taken in by the misinformation as competitive, spoiled and careless is not that accurate or helpful.

            I mean, I’m sure there are some women who’s motivation is not that admirable. But then again I’m sure there are some women who have very conventional births who’s motives are not that admirable either.

            *not my idea of nice, to be honest.

            1. WilliamLawrenceUtridge says:

              Hi Mouse, clearly I don’t know the difference between an Anesthetist and an Anaesthesiologist :)

              Yeah, the bluntness of my opinion does disguise a minor bit of nuance. I realize that what I refer to as “sport birth” mothers do value their own health, and the health of their child. For me, it’s more a matter of “nothing else matters”, because I can’t see what else could matter. But yeah, that’s my personal opinion. To value it as an experience is bizarre to me. And I think they underestimate the risks to mother and child during birth. Sure, people have given birth for millions of years. Sure, even in those circumstances the death rates are relatively low. But they’re very far from zero, and these low-likelihood events are extremely high impact when they do occur. I don’t think that is appreciated. I agree with your statement that they are given “misinformation”, but part of that incorrect information comes from their own filter and opinions based on pure Dunning-Kruger as far as I am concerned.

              1. mouse says:

                WLU “Hi Mouse, clearly I don’t know the difference between an Anesthetist and an Anaesthesiologist”

                Anesthetist is a certified registered nurse anesthetists or CNRA, which is an advanced degree nurse specializing in anesthesia. Anaesthesiologist is a physician specializing in anesthesia. They are both very prevalent in surgery and OB. If you are curious check out the scope of practice section of wiki for an overview. http://en.wikipedia.org/wiki/Nurse_anesthetist

                “For me, it’s more a matter of “nothing else matters”, because I can’t see what else could matter. But yeah, that’s my personal opinion. To value it as an experience is bizarre to me.”

                Here’s an example of what else might matter. any gynecological procedure can be intrusive to the point of feeling sexually abusive…even if that intrusion holds NO physical risk to the woman or fetus/infant. Feeling reasonably comfortable with your doctor and the other medical staff is part of the “experience”

                It is not medically necessary to warn a women before touching during a cervical exam – but it is an unpleasant experience for the patient to be touched in a private area without warning. Generally, I think that I should be able to request an experience that I am comfortable with and most of the time that is not in conflict with safety. If there IS possibly a conflict with safety, it still is not a black and white issue. If there does come a time when “the experience” must be discarded due to an emergency – A physician doesn’t wait to inform the patient before touching so that they can stop a hemorrhage, isn’t that going to negatively impact the patient less if her comfort and autonomy has been respected up to that point?

                This does not seem to be an approach that the majority of doctors here have a problem with. It seems like you are coming across as more militant than the doctors who have experience with these situations. Am I reading you wrong?

                As Clay Jones said and I agree- The majority of women are not choosing an experience over safety. They are looking for a situation that is safe for them and the infant and will be comfortable and nurturing.

              2. mouse says:

                Doh – make that CRNA not CNRA. I’m getting my nurses mixed up the gun advocates. Not good.

              3. WilliamLawrenceUtridge says:

                Here’s an example of what else might matter. any gynecological procedure

                Yeah…don’t have a vagina…but I see your point. However, my opinion of this would be “sure, it’s nice if you get a warning, that’s a great courtesy; but the real measure of a doctor’s worth is their ability to prevent death and serious suffering”. A procedure might feel intrusive, but in most cases I would assume the procedure is being conducted out of medical necessity. The way something feels says more about the patiet’s interpretation than it does about the medical necessity. I’ve had a digital rectal exam before. It could have felt like prison rape (not really, I exaggerate for effect) but the reality and intent is different. I try to ignore and minimize my own interpretation of the procedure in favour of focussing on the results, which I trust my doctor to be the best possible, to the best of his abilities.

                Again, my approach to being a patient is to cede all my autonomy to the doctor. In the absence of incompetence or active sexual abuse, my assumption is that what is being done is necessary and with the minimum of discomfort, because doctors don’t want to cause me pain or be more intrusive than necessary. Probably not always true, but I trust that it is true in most cases.

                Regards to childbirth, the time for nurturing is, again in my opinion, when the baby and mother are both safe and morbidity and mortality to either is not in question. Absent frank trauma, the baby will not be psychologically traumatized by the birth. Their personality is determined by genetics and the millions of interactions with parents, family and friends over the course of decades. Not whether or not they were floating when pushed out of the birth canal. Nothing you can do can make that push better, and the bare minutes afterward won’t make any difference to the kid.

                This does not seem to be an approach that the majority of doctors here have a problem with. It seems like you are coming across as more militant than the doctors who have experience with these situations. Am I reading you wrong?

                Oh, no, I’m sure I’m far more militant than the doctors. It’s my own Dunning-Kruger, it’s easy to be militant when you have no experience (beyond being an acutal patient).

      2. windriven says:

        “My guess is that the “dissatisfaction” is similar to CAM-promoters dissatisfaction with real medicine…”

        William, my guess is no more valid than yours. But in a lifetime of talking with people – some band-edge wooistas excepted – the dissastisfaction that I’ve been told of is much more reasonable and rational than that. Mostly it is from people whose contacts with their physicians leave them uncertain, uninformed and with the sense that they have no control. The endpoint of a healthy mother and baby is certainly the primary endpoint but when it is the only endpoint the job is left half-done. Perhaps patients should just show up, answer the physician’s questions, and do what they’re told?

        1. WilliamLawrenceUtridge says:

          Perhaps patients should just show up, answer the physician’s questions, and do what they’re told?

          That’s how I treat my visits to my doctor, because I’m not a doctor.

          Perhaps the distinction is in what is valued. I simply can’t see anything more than “healthy baby, healthy mother” as important. I simply can’t understand anyone who places any aspect of the “experience” over that. You ever watch ER? Remember the scene where Chloe gives birth and spends all that time bitching at people to get her the right tape for her absurdly inconvenient boombox so she can listen to “Blackbird”, as if having the right music playing at the moment of delivery will magically ensure a perfect child, teenager and adult? I spent the whole time yelling at the TV.

          Yeah, doctors shouldn’t be rude. Yeah, they should have good bedside manner. But ultimately, they know so much more than me, there’s almost no point in me having an opinion unless there are two close options and I need to choose which sequelae I would prefer. The rest of the time? Please doctor, you tell me what to do.

          This is your health. Life is fleeting and precious and uncertain. Medical care has consequences and should be taken seriously. Everyone’s opinion is not equal.

          I’m not saying remove all patient autonomy; I voluntarily give up my autonomy because the chance of me having something meaningful to contribute is pretty close to zero. I don’t advocate snipers with vaccines tagging people from rooftops (actually, that would be badass, I could live in a world like that). But part of what irks me about CAM in general is that it is treated as a great equalizer, as if everyone has a body so everyone gets an equal say. That’s a delusion. It irks me that so many people don’t realize that they should give up their autonomy because they think it’s all simple.

          Ultimately Windriven, I bet given the same scenarios, we would probably have very similar opinions about the actions to be taken. We would probably even agree on how much autonomy patients should be given, the latitude of their choices. We would probably have similar amounts of sneering contempt for the people making stupid ones (after all, sneering contempt is what this site does best :)!) I’m not even sure where our differences in opinion lie here, in pragmatic terms. Perhaps solely in the non-medical arena (though we’d probably be on the same side when it comes to drug legalization). Maybe the only difference is in emphasis – I feel like you would place more effort and volume on patient autonomy while I would place more emphasis on how stupid their decision was.

          What do you think?

          1. mouse says:

            Shoot – I sent this to comments this morning but it didn’t go through (our wifi is acting up). I’m going to post it because, what the heck. But apologies for redundant thoughts.

            Windriven”Perhaps patients should just show up, answer the physician’s questions, and do what they’re told?”

            WLU “That’s how I treat my visits to my doctor, because I’m not a doctor.

            Perhaps the distinction is in what is valued. I simply can’t see anything more than “healthy baby, healthy mother” as important. ”

            WLU – Forgive me if I misunderstand – but you seem to be making an argument that doctor/patient partnerships and doctors respecting patient autonomy is intrinsically in opposition to better/safer outcomes. But it seems to me that often these partnerships results in better outcomes that are more mutually satisfying to both patient and doctor.

            Also, In my mind just unquestioningly following doctors orders is a luxury for folks who are very healthy and/or have lucked into an excellent doctor. I didn’t question my doctors up until the day that one gave me an inflated success rate for a proposed IVF. Then I started to say, hey, maybe I should be more critical – less trusting.

            Many doctors are excellent, It seems to me that the vast majority of medical folks on this board show us that. But there are doctors in practice today that are not so excellent, not so trustworthy and unfortunately, don’t care so much. If that weren’t the case, there wouldn’t be a need for this blog.

            If you want to approach your medical care by just answering questions and following orders. That’s fine, that may be the best approach for you considering your health and current doctors.

            But I feel as if you are, probably unintentionally, portraying those of us who ask questions, doubt and criticize care that we feel was substandard, disrespectful or otherwise more painful or stressful than needed as Dunning Kruger deluded arrogant prima donas. It’s not an all or nothing thing. There is a lot more to healthcare than CAM/no CAM. There are many perfectly reasonable concerns about patient/doctor decision making, patient autonomy that just don’t fall within the purview of the CAM discussion, but still need to be considered when a patient decides whether they should just answer the doctor’s questions and do as told.

            (sigh) Windriven is actually much better at communicating this stuff than me. I’ve probably completely flubbed it and unintentionally insulted a bunch of people who I actually think are doing a darn good job.

            1. Windriven says:

              I’d say you did just fine.

              Speaking for myself, I have the ultimate responsibility for my health from the foods that I eat, the exercise I take, the physicians I choose.

              I have excellent relationships with my physician, my attorney and my CPA. I ask them all hard questions. I demand detailed explanations. I don’t always agree with their advice but I always follow it unless I have other informed professional advice that offers a substantially different approach.

              1. mho says:

                Yes, ultimately, you have the burden of managing the life you have now–is that what you meant by saying you have the ultimate responsibility for your health?

                There’s quite a long list of health factors that extend beyond one individual’s choice.
                I’d say you have the ultimate responsibility for the exercise you choose, if you are fully physically abled. But the quality of your food will partly be determined by your wallet, and/or the resources available for gardening and farming. The pool of doctors you choose from may be determined by your location The pool of available doctors may be determined by your race or your age or again, your income. The quality of the air you breathe is determined by location. The quality of the water you drink is determined by location and your income: can you afford to import water if your own is contaminated? Your location may be determined by your family obligations. Your income may be determined by your health.
                Some of your gene structure is pre-determined. You may also have had illnesses in your childhood that have effects later in life.

              2. windriven says:

                @mho

                You may be overthinking what I said. My point is that each individual is responsible for his or her own health within the scope of control available to them.

                Contrast that with the notion held by some that their health is their physician’s problem. They present with x and the physician makes it better. This ignores their responsibilities in eating healthfully, exercising regularly, being vaccinated, etc.

                And yes, you can find outliers and exceptions like the impoverished. But then poverty is a socio-economic problem. The health consequences are manifestations secondary to the root problem.

            2. WilliamLawrenceUtridge says:

              but you seem to be making an argument that doctor/patient partnerships and doctors respecting patient autonomy is intrinsically in opposition to better/safer outcomes. But it seems to me that often these partnerships results in better outcomes that are more mutually satisfying to both patient and doctor.

              Not in all cases. In this case, water birth, yes, yes they are. The very act of wanting a water birth is stupid, carries no benefit, presents many risks, and merely the act of expressing a preference puts the doctor’s concerns (healthy baby, healthy mom) at odds with the mother’s (“an experience”). As far as I am concerned.

              As Dr. Jones says though – I’m talking about water birth, not a pre-birth bath.

              Also, In my mind just unquestioningly following doctors orders is a luxury for folks who are very healthy and/or have lucked into an excellent doctor. I didn’t question my doctors up until the day that one gave me an inflated success rate for a proposed IVF. Then I started to say, hey, maybe I should be more critical – less trusting.

              Yeah, I would agree – I have had no major health complaints in my life, and the minor ones that I have had have required minimal, short-term interventions. And this only applies in situations of with well-validated interventions, well-understood conditions, and the absence of woo-nuttery. Woo in and of itself is harmful and corrosive to the doctor-patient relationship.

              But I feel as if you are, probably unintentionally, portraying those of us who ask questions, doubt and criticize care that we feel was substandard, disrespectful or otherwise more painful or stressful than needed as Dunning Kruger deluded arrogant prima donas.

              Not all patients and not all mothers. But definitely the ones who want to give birth in a bloody toilet.

              There is a lot more to healthcare than CAM/no CAM. There are many perfectly reasonable concerns about patient/doctor decision making, patient autonomy that just don’t fall within the purview of the CAM discussion, but still need to be considered when a patient decides whether they should just answer the doctor’s questions and do as told.

              This might actually be the nub – my comments apply to cases of CAM, such as water birth and other stunt births. In cases of genuine uncertainty for real medical care, and there are such circumstances of course, I might change my mind. Probably will in fact. But when talking about something as obviously stupid as water birth, naw, no compromise.

              1. mouse says:

                “As Dr. Jones says though – I’m talking about water birth, not a pre-birth bath.”

                Actually, I think it would be helpful if you were much more specific about what you are talking about.

                Because your initial comment said “at least for the wealthy, middle-to-upper class white folks who support a lot of parenting woo and nonsense,”

                So first you’re talking about parenting woo and nonsense – is that parents who give vitamins, parents who wear their babies, parent who put BabyEinstein on the TV, moms who don’t want epidurals, home birth?. It’s a completely nebulous criteria. Then you say ‘natural child birth’ is an uninformed stupid choice, but turns out that’s not the natural child birth that most people mean, it’s home birth with a lay midwife. Now we have narrowed it down to women who choose to deliver underwater. Okay!

                But it seems like you are basically shooting your rifle with your eyes practically closed, then drawing a circle around where the bullets hit and shouting “Bulls-eye!”

                And you are bemused why some people are laying on the ground with their hands over their heads shouting at you. :)

    4. mouse says:

      @Windriven – Rebirthing along with other “attachment therapies” was one of the strategies being used that resulted in the death of Candace Newmaker.

      Not a good sign.

    5. Sullivanthepoop says:

      I do think that the whole fact that we are even talking about appropriate pain relief during childbirth is misogynistic. If men gave birth I guarantee we would not still be talking about this.

      You know when I was 18 I had my wisdom teeth taken out and they gave me a prescription of percocet. I took them for one day. I didn’t think the pain was bad at all. I think I should start a movement where pain relief for wisdom teeth extraction is bad. This makes as much logical sense as the other, but no one goes around talking about whether they had much pain with most procedures.

      1. mouse says:

        sullivanthepoop “I do think that the whole fact that we are even talking about appropriate pain relief during childbirth is misogynistic. If men gave birth I guarantee we would not still be talking about this.”

        Even talking about it? Really. I had a cervical epidural for a ruptured disc/radiculopathy and when I run into other people (even men) with the same condition who had the procedure we talk about it. What were the side effects, did it work, was it worth it or should we have waited, maybe the symptoms would have resolved on their own….

        I don’t get it. What’s so misogynistic about talking about it? And isn’t it kinda hard to do informed consent if you don’t talk about it?

        1. Windriven says:

          I’m with you, mouse. The exchange of information is not misogynistic; the insistence on a male perspective is misogynistic. In childbirth the decisions about pain management are ultimately the mother’s. The physicians (obstetrician and anesthesiologist) should do their part with information necessary for an informed choice. The baby daddy might offer his perspective. Then it is time for all the pie holes to shut. Except the mother’s.

  2. Kathy says:

    “complementary and alternative reality” … indeed it is! Just love the expression. Can I steal it?

    1. Clay Jones says:

      Sure, although I can’t say I originated the phrase. This is the earliest example I could find. http://www.quackometer.net/blog/2010/10/the-curious-case-of-oxford-university-press-homeopathy-and-charles-darwin.html

      1. David Gorski says:

        Yeah, it’s kind of like “quackademic medicine.” I wish I could claim that term, but someone else thought of it. The earliest example of its use that I can find comes from 2008:

        http://doctorrw.blogspot.com/2008/01/exposing-quackery-in-medical-education.html

  3. empliau says:

    Great piece! Even seals would drown if born underwater, though …

    1. Clay Jones says:

      I’ve actually just figured that out based on a comment over at Skeptical OB. As I stated there, I let my zeal for a biting remark cloud my thinking.

      1. empliau says:

        I didn’t post to nitpick – you could have said dolphins, whales, whatever. But even animals as well-adapted to marine life as seals give birth on land. So I think it’s a brilliant example. If land birth is good enough for Our Friends the Pinnipeds, it’s good enough for me! Also, even though laboring (not giving birth) in water is supposed to be relatively safe, I can’t imagine trying to get out of a tub in mid-contraction, naked, slippery, and cold. That seems like a potential trainwreck I wouldn’t want to risk for my baby or myself.

        1. Calli Arcale says:

          There are a bunch of mammals who, by nature of their anatomy, actually have even more perilous births than we do — at least in terms of infant mortality. I think we set a pretty high bar for maternal mortality thanks to our freakish noggins. Dolphins and whales may have as high as 50% infant mortality rates. And yes, many of these are due to drowning — even an animal adapted to spend its entire life in the water must breathe immediately after birth or it will die. Dolphins often have assisted births — another female in the pod will often help push the baby to the surface to breathe before it suffocates. We marvel at horses running an hour after birth, but dolphins must be completely mobile as soon as they exit the birth canal or they will not survive their first minute of life.

  4. Harriet Hall says:

    Clay, you beat me to the punch. I had just finished writing about the same subject for my next Tuesday contribution. I’ll go ahead and post my version anyway: if it’s worth saying once, it’s worth saying twice, and different approaches may appeal to different readers. One thing I love about this blog is that each of us has a different method and style, and we travel to our conclusions by different routes, but we invariably end up in the same place because we all use the same standards of science and reason.

    1. Clay Jones says:

      I’m sorry about that Dr. Hall. I look forward to your take on this.

    2. Zoe237 says:

      Oh, I hope you will still post it! I have found your take on SBM usually to be very fair and well reasoned.

  5. Zoe237 says:

    Agree with WD. One of the weaknesses of SBM is the denial that something besides mortality and morbidity might matter to people or affect one’s overall health. This is by no means all science based practitioners, but I occasionally hear derision. As someone pointed out, childbirth is not simply a medical procedure to many of us. And I hear a lot more condemnation of judging of mothers who choose Ncb as being “stupid” or “caring more about the experience than their poor defenseless babies” than the other way around. I haven’t read the customer satisfaction link yet, but I don’t believe patient centered care is mutually exclusive with positive health outcomes or evidence based practice.

    And yes, there are (minimal) risks of epidurals to mother and baby. For the majority of us, the benefit of pain relief outweigh those minimal risks. But we also don’t make benefit-risk assessments the same way.

    The thing that annoys me is when doctors prescribe antibiotics for a virus just to keep the patient happy and feeling like they didn’t just waste that money and time.

    1. Clay Jones says:

      I absolutely don’t think of women choosing a natural birth to be stupid, or to put their experience above the health of the baby. I worry that many who choose this option are doing so using bad information, however. Or are led to believe that it is a better choice based on the desire to achieve some kind of idealistic experience because of cultural and societal influences. The question at hand is are they truly making an informed decision? We can address one part of the problem with education, but I don’t think we will be able to do much with the other. Besides, we run the risk of sounding paternalistic, implying that woman don’t really know what’s best for themselves.

      1. WilliamLawrenceUtridge says:

        Heh, my take is that because they are making a decision with bad information (to have a natural birth) they are making a stupid choice. This is informed by years of reading and the gradual realization of just how little I know (and some reading on the low-likelihood, high-impact events that can accompany childbirth). I simply can’t make an informed decision about a medical matter without spending a good half-decade just reading – and then I would still fall short of the experience of even a medical student. I know my limitations are profound and don’t pretend I can contribute to a discussion beyond selecting options. I’ve informed myself to reach this point.

        The idea that you can inform yourself by reading a couple natural health blogs and listening to the ill-informed prattle of a doula or midwife who didn’t graduate high school is laughable.

        This might all be a special case matter due to the topic being the profoundly unscientific natural childbirth movement (and all CAM), that insists childbirth is riskless, easy and predictable. With real medical issues, not fake ones like these, there’s much greater confidence in some areas, and uncertainty in others.

        1. mouse says:

          WLU “I know my limitations are profound and don’t pretend I can contribute to a discussion beyond selecting options. I’ve informed myself to reach this point.”

          It appears that you ARE contributing to the discussion though – to the point of saying that you think the decision to pursue a natural childbirth is stupid.

          Of course WLU, you have a right to your opinion. But I don’t think you have medical training, you don’t seem to have much particular knowledge of labor and delivery, beside reading the SkepOB blog and you can’t have any knowledge of the individual circumstances that these “natural” births may take place – where they will take place, who will be attending them, whether they are high risk or low risk, etc.

          So your opinion seems to be just that, a personal judgement based on your own preferences. Which is cool. You probably shouldn’t pursue a natural childbirth.

          1. WilliamLawrenceUtridge says:

            It appears that you ARE contributing to the discussion though – to the point of saying that you think the decision to pursue a natural childbirth is stupid.

            Specifically the unnatural practice of water birth, and the beliefs that doctors don’t care about your health, that childbirth is risk-free, that maternal and infant deaths are uncommon (which they are, to a certain extent, but still far more dangerous than most of the events which we take for granted on a daily basis like driving), the idea that childbirth pain is purely psychological, the idea that anything but a vaginal birth dooms your child and you to a loveless relationship, the idea that anything but vaginal childbirth is somehow “less authentic”, that C-sections are purely for convenience and there is no consideration of safety in the doctor’s decision, the idea that a garlic inserted into the vagina prevents infection, the idea that all you need is a weekend of training to savely deliver babies on a regular basis, THAT is what I mean by “natural childbirth”. Which is to say – I am really talking about all the CAM nonsense that accretes onto delivering a baby.

            I have no problem with someone giving birth without pain control, in a hospital. Giving birth at home just seems like a terrifying idea to me, because all I would be able to think about would be the baby choking to death on the umbilical cord, or my wife bleeding out while I watched helplessly, or a bit of placenta remaining inside and gradually rotting, leading to sceptic shock.

            I know someone here gave birth deliberately at home (Chris?) I believe out of reasons of distance and fear of hospital-acquired infections. While I heartily disagree with the idea, I’m horrified by it, at least the idea was made on the basis of (from what I can tell) real and meaningful information – not a whole bunch of paranoid anti-doctor ranting about golf and greed.

            Yeah, personal judgement, a bit more nuanced than my throwaway lines would present. Definitely more dogmatic than a lot of doctors, probably something that will make some commentors (Chris?) bristle at for the implied judgement of their choices. Meh, I would never advocate for my opinions to become mandatory or enshrined in laws. I mostly object to the idea that CAM birthers are making “informed” decisions when really it seems to be mostly about rejecting authority and having an “experience”. And I’ll never pretend to respect it.

            Child birth and rearing brings out the opinions in all of us!

            1. brewandferment says:

              no, it was me not Chris and in a nutshell besides hospital infections it was also the fact that my evidence based OB couldn’t ensure her presence to fend off the interventions I didn’t want and that have been clearly recognized here on SBM as not useful. Such as: non-ambulatory continuous fetal monitoring, denial of hydration and nutrition, rigid progression timelines that weren’t based on good data (means and error intervals all over the map).

              There were also too many older OB types on staff that didn’t want to change practices to even follow the evidence (let alone make me at ease). When I was the one doing most of the work, I didn’t want to expend precious energy trying to get them to support what was helpful to me during a very meaningful time of my life.

              Pain from childbirth is still quite DIFFERENT from injury pain! I spent part of my labor in the jacuzzi and it was a great help but never did my midwife indicate she preferred me to eject the baby into it.

            2. mouse says:

              Thanks for the clarification WLU – Usually people I know who talk about natural childbirth are talking about childbirth in a hospital (birthing room) without pain control with a low risk pregnancy …They understand that sometimes surgical intervention could be needed and safety interventions are accessible, since they are in a hospital. Usually people specify home birth as such. So being so avid about people interested in natural childbirth without a clarification on what specifically is bothering you is a bit confusing.

              Yes birth and parenting bring out the opinions in all of us. I think 90% of my decisions as a parent are severely disapproved of by somebody, somewhere. Oh well! But it’s a bit of a contradiction to complain about sport birthing then turn around and be the monday morning quarterback. You can’t expect I won’t ping on you for that. I’m just too evil.

              1. windriven says:

                “talking about childbirth in a hospital (birthing room) without pain control with a low risk pregnancy ”

                That is my understanding as well.

            3. Chris says:

              “I know someone here gave birth deliberately at home (Chris?) ”

              No way. The first kid ripped me from stem to stern, which required me to stay hospitalized for two extra days. The baby was transported by ambulance to the children’s hospital when he was forty eight hours old. I had one last miserable night in the hospital.

              During the week the baby was in the intermediate infant care ward I was taking antibiotics for a post partum infection.

              I would be the last person to give birth at home. Though my daughter was born within ten minutes after we arrived to the hospital birthing room. I yelled at my hubby to stop getting coffee and get next to me!

              I have never had an epidural, because I slip through the dilation window of opportunity too quickly.

              1. WilliamLawrenceUtridge says:

                For some reason I apparently get you and brewandferment mixed up. Is it a compliment? Is it an insult? I enjoy both your comments, perhaps that’s the link.

    2. Harriet Hall says:

      @Zoe237.

      “One of the weaknesses of SBM is the denial that something besides mortality and morbidity might matter to people or affect one’s overall health. ”

      Has SBM has ever denied that? I don’t think so. I certainly don’t. SBM’s goal is to provide accurate information. Informed people can then consider not only mortality and morbidity but personal values, philosophies, and preferences. That point has been made times on this blog. We consistently support patient autonomy, one of the core principles of medical ethics. Just one example: I support Jehovah’s Witnesses’ right to choose death over transfusion for themselves, although I don’t think they have the right to deny their children live-saving blood transfusions. There is an argument for overriding autonomy if it puts other individuals at risk.

      1. Zoe237 says:

        I definitely don’t think you Dr. Hall deny that patient satisfaction matters- your people skills come across in your posts. Nor do I think Dr. Gorski doesn’t care, despite his slightly snarky online persona. ;-) The others here I’m not sure. What do doctors prefer, an engaged patient or someone who does what they are told? I come from a long line of family members who question their healthcare. We don’t have any medical doctors in the immediate family, but lots of teachers, engineers, pharmacist, nurse practitioner, psychologist, generally smart, middle class people. What I leaned from observation is that it makes sense to read journals and research, bring lists of questions, and ask about different science based options for care. For example, an aunt had breast cancer, my uncle had heart disease, and my brother had an inner ear bone infection. That doesn’t mean not listen to the doctor. Every doctor I have had has been open to questions and likes explaining the benefits and risks to different choices. I guess it could be annoying to some, but I want hard numbers, statistics, and preferably citations. ;-). Those answers also tell me the doctor knows what the heck he or she is talking about and is current in the field. Also, ime, the best doctors I have to wait the longest for- they take time to help a patient to adjust to sometimes devastating news, and explain treatment process.

        I also have said before that a few extremists on this website (commenters mostly) go too far in the other direction, and that science does not always equal technology. Sometimes it IS better to let nature takes its course, to wait and see if the body heals itself, or too avoid tests that might have high false positive rates. There is NOT a nature vs science dichotomy! My passion is science education (specifically evolution and teaching people to think scientifically), and my goal is to teach students to ask questions, be empowered, and think about risks and benefits to life decisions in general. It is also important to learn how to trust authority and make judgement calls about an authority figure or organization’s reputation. There is such a fine balance there.

        As for my own NCBs, I was thankful to have a very supportive doctor who respected my wishes to not have medication if I could handle it, not have a catheter, be able to move about, avoid a cesarean, use hot water for pain relief, not have an episiotomy or stitches, and leave the next day. Of course, I would have accepted any of these if they were necessary, but they weren’t for me. Why do people on both sides of some odd debate assign morality to those choices?

        1. Zoe237 says:

          Also, my question is always the why, not the condemnation, and how can we improve science education so that people can be informed consumers of medicine, yet not go off the deep end and start questioning interventions with decades of solid research like vaccines or use google for diagnosis central. Refusing vaccines is clearly stupid, as is turning to homeopathy. But there is a gap there that causes otherwise smart people to turn to pseudoscience. Why? How can we solve these gaps in understanding?

        2. WilliamLawrenceUtridge says:

          This might all be a special case of CAM vs. Real Medicine. I don’t think you can enter a conversation with a real doctor about CAM and expect much respect, particularly if you approach it as the usual CAM believer does – conspiracy, conflicts of interest, concealment of “natural” cures, and whatnot.

          To whit, Zoe, you would not in my mind want a “natural” child birth in the same way someone trying water birth would. You prefer a low-intervention birth, but all of your options are evidence-based and I suspect you wouldn’t consider your birth “ruined” if you had to have a C-section, episiotomy and stitches with a week-long stay in the hospital afterwards. You might be disappointed, but I would guess you wouldn’t want to have another baby purely for the sake of having a better “experience”.

          There’s a fundamental difference between CAM and real medicine, and I think the former grossly underestimates the dangers of many aspects of health and medicine.

          1. Zoe says:

            No, I didn’t want a natural childbirth because it was natural, but because I play soccer several times/ week, run, was going to school during the time, and very active. I don’t like to slow down if I can avoid it, and I didn’t want to increase my chances of surgery. If a c-section was necessary, I’m sure I would have had a couple of weeks where I had to slow down, but I can’t conceive of feeling like my body had failed or something. I guess the point is that women want different things for many different, sometimes cultural, social reasons. As long as there is informed consent, I think patient preference is great. I know several local hospitals offer water birth around here. I wonder if they will stop offering it in light of this policy. I’d just like to see more respect all the way around for women’s childbirth choices, if they aren’t risky. And even if they are risky, let’s use logic, science, and statistics, not name calling or condemnation.

            1. WilliamLawrenceUtridge says:

              Again I circle back to what “informed” means. For some, “informed” means finding out what the experts have to say. I have no problem with people “informed” in this manner.

              For others, “informed” means finding out what the internet says. That’s misinformed and dangerous, and comes front-loaded with a whole bunch of Dunning-Kruger and substitution of rhetoric for actual information. Those are the people who think medicine is driven solely by money, who think doctors care more about PharmaBucks than patients, and who think nature offers a cure for all disease. And they’re wrong.

  6. Crankyepi says:

    “One thing that happens in a water birth, you as the attending physician pretty much have to stand there with your hands in your pockets and let it happen without your participation. That is pretty scary to a physician-oriented institution.” Actually, the physician doesn’t come in to the L&D room until the end anyway. So, I doubt that they’re concerned about standing around with nothing to do. They have plenty of patients to see in the office!

    “Expectant mothers, and often their families, put a great deal of focus on the subjective experience of childbirth…” Yes, I think this is true and yet in the grand scheme of things the “labor and delivery experience” is minor compared to the job of raising a child. The “Earth Mother” types are fond of saying that if the labor and delivery isn’t done right, it interferes with mother-child bonding – um, what is the evidence for this?

    Having had two kids, I seriously doubt there is much if any labor pain reduction from sitting in a tub of warm water. When I was pregnant with my first child I watched a reality show where the mother was laboring in a bath tub at home. She kept yelling “Jesus save me!!” and otherwise looked pretty uncomfortable. P.S. I realize this is anecdotal but couldn’t help relating it.

    If a labor and delivery are going to go well, the baby can be born pretty much anywhere. The problem is that there is no guarantee for any mother, regardless of her history, that the labor and delivery are going to go well. Childbirth should be thought of as somewhat dangerous (my opinion) – think of how many women and babies died before the evil doctors came along.

  7. Jon Brewer says:

    Would you believe I was waiting with bated breath for a mention of the aquatic ape hypothesis? Never mind that AAHers’ definition of ‘aquatic’ pretty much means ‘occasionally drinks water’.

    Anywho, ‘natural’. You keep using that word, alties. I do not think it means what you think it means. Somehow I doubt an enema with enough pressure to puncture your colon is natural, but it’s said to be natural by oh so many quacks. Eating 8 melons’ worth of vitamin C in one pill certainly isn’t natural, but Pauling said it was. Same thing here.

    (And yeah, when I first heard of water birth, my first thought was ‘so many ways this cannot end well’.)

    What’s interesting is, the “my method works better to address _issue_ than a simpler method” approach. I’ve started calling it Vegan Fallacy because I’m lactose intolerant and vegans tell me that means I can’t eat meat. (lolwut) In this case, while C-section and episiotomy are overused, there’s nothing about water birth per se that would reduce their frequency (other than the philosophy that a physician is at best just there for show). You could simply have more stringent requirements for when birth through surgical means is done. You don’t need to give birth in a tub of water, introducing the risk of drowning and exposing the neonate to potentially a number of pathogens, to do it.

    1. windriven says:

      “Would you believe I was waiting with bated breath for a mention of the aquatic ape hypothesis?”

      I was going to jump on it but Dr. Jones did mention it in the post.

      1. Clay Jones says:

        Yeah, one of the links I put in the post mentioned our “aquatic interlude” as evidence in support of waterbirthing. I don’t think they meant the Cambrian period.

        1. mouse says:

          It reminded me of the Kurt Vonnegut novel Galapagos. Perhaps water birth will be more appropriate when our brains are smaller and we have flippers instead of hands. Then the ghost of Barbara Harper can say I told you so.

    2. mouse says:

      @Jon Brewer – I have no idea what an aquatic ape is, but your comments crack me up. Thanks.

      1. Andrey Pavlov says:

        @mouse:

        The <a href="http://en.wikipedia.org/wiki/Aquatic_ape_hypothesis"aquatic ape hypothesis was a proposed evolutionary turn that led to us. The basic idea is that some apes became semi-aquatic which led to an advantage of having less hair and standing more upright and thus the (nearly) hairless apes you see around you.

        It never had much support and is now since long gone the way of the dodo. No evolutionary biologist worth their salt takes it seriously these days.

        1. mouse says:

          An apelike species that lives in the water long enough to lose it’s body hair but walks upright in the water, rather than swimming…like just about every other aquatic mammal?

          I’m not saying it couldn’t happen. There’s some very counter-intuitive animals out there. But I’d put my dollar on Vonnegut’s version first.

          1. windriven says:

            “An apelike species that lives in the water long enough to lose it’s body hair but walks upright in the water, rather than swimming”

            Of course, mouse. That is why we have webbed hands and feet and gills instead of lungs.

            1. mouse says:

              Well – some people are born with webbed hands and feet. I think there’s another explanation for that that doesn’t require us to rely on the aquatic apes theory though.

              1. Windriven says:

                That bastard Kermit!!!

              2. Harriet Hall says:

                “some people are born with webbed hands and feet. I think there’s another explanation for that”

                The explanation is in embryology. The hands and feet start as paddle-like structures, and the connecting cells between the digits-to-be are then eliminated. Sometimes the process is incomplete. For an illustration showing where the cells die, go to http://islampapers.com/2012/04/01/bone-and-muscle-2/ and scroll down to the picture labelled “Early Forelimb Skeleton.”

        2. WilliamLawrenceUtridge says:

          I don’t think any evolutionary biologist ever took it seriously. John Langdon reviewed the latest book that attempted to summarize (in a series of mutually-contradictory chapters) the “research” on the topic. It was interesting reading (nice guy, he sent me an advanced copy PDF upon request) mostly for the way he points out the various contradictions. His biggest point was, if I recal correctly, “proponents really need to clarify what they believe rather than proclaiming themselves victims and thus victors.” Classic Gallileo gambit.

    3. WilliamLawrenceUtridge says:

      Also not natural:

      Puncturing the skin with filiform needles (I mean, cacti use needles to keep animals away, why would it have beneficial effects?)

      Filiform needles.

      Crushing a substance, immersing it in alcohol, repeatedly diluting and shaking it, then sprinkling it on lactose pills.

      High-concentration alcohol.

      Lactose pills.

      Bananas that you can eat without breaking a tooth.

      The computer you are typing your screeds about how evil medicine is.

      Your smallpox-scar-free skin.

      Your children surviving at percentages in the double-digits.

      Your current life (assumes you are older than 35).

      Having all your fingers.

      Nature sucks.

    4. Sullivanthepoop says:

      Epidurals are no more overused than any other pain relief people feel they need when they are in pain. I also doubt C-sections are overused.

      1. WilliamLawrenceUtridge says:

        Actually there’s a lot of discussion in actual medical journals regarding whether C-sections are overused. It’s a hard question to answer, and at least part of it is because of the not-necessarily-appreciated consequences of C-sections over the long-term. A C-section isn’t necessarily a big deal or bad thing if you’re having one for your last/only baby, and probably isn’t much worse than an episiotomy in terms of recovery (best, of course, is vaginal delivery with no long-term health consequences, ha). But if you’re planning on, or get pregnant afterwards, the risk of the placenta growing out of the womb, through the scar tissue, increases with each subsequent pregnancy – with pretty nasty consequences. So real doctors debate over this point, and where is the line to be drawn (and can a line be drawn over how many is too many). Mean while their natural childbirth critics ascribe it all to greed and golf games.

        One of the many examples where a genuine scientific debate is hijacked by CAM promoters and turned into something it is not.

        Information from Nathanael Johnson’s All Natural.

        1. windriven says:

          That was a most interesting passage in All Natural. I had tended to accept C-section as a perfectly legitimate choice that posed little risk, in fact perhaps less risk than vaginal delivery.

          Might be a good time for Dr. Hall to consider a post on the subject.

          1. Harriet Hall says:

            C-sections carry significant risks. They may be either more or less risky than vaginal delivery depending on the individual situation. They are usually done when the obstetrician judges that they will be safer than vaginal delivery for that specific case. They are definitely more risky than vaginal births when done for non-medical reasons (for instance, to fit in with a doctor’s schedule or to accommodate a woman who wants to deliver on a specific date or who doesn’t want to go through labor and vaginal delivery).

            1. windriven says:

              Thanks again for recommending All Natural Dr. Hall. I read it on a long flight and really enjoyed it.

              Also, I do think it might be timely to revisit current thinking on labor and delivery, vaginal versus section, the role of midwives, etc. I’m not sure how obstetrics are practiced in the Seattle area but in the Portland area some hospitals accomodate midwives.

              1. Harriet Hall says:

                We had nurse midwives in Air Force hospitals where I worked decades ago. They were not only accommodated, but were welcomed and very much appreciated.

              2. WilliamLawrenceUtridge says:

                I really wish they would clarify the nomenclature for midwives in the US, or simply prevent the unqualified ones from practicing.

                Something like “nurse midwives” for ones that are actually nurses, and “Kindermorderzu” for the other kind.

              3. mouse says:

                WLU – Officially it’s Certified Nurse Midwife – CNM. Which is another advanced degree nurse. People often just say midwife, though. So you can’t just assume “midwife” is someone without training, but you can’t just assume any “midwife” is a CNM.

                Don’t they have advance degree nurses in Canada?

              4. WilliamLawrenceUtridge says:

                That’s rather my point though – there are two types of midwives in the US – certified nurse midwives/the ones who know what they’re dong, and whatever the other baby-killing kind are called (direct entry midwives?) and the latter are parasitic on the former. In much the same way that “doctors” of chiropractic are parasitic on actual physicians, and CAM is parasitic on actual medicine and science.

                Yeah, in Canada the only midwives are the real ones, not the pretend ones who kill babies.

          2. WilliamLawrenceUtridge says:

            Agreed, probably one of the most fascinating areas for me because I had hitherto-no appreciation of it! A seemingly-tiny gap in my knowledge that was cracked wide open to reveal the vast cavern of ignorance beneath.

            And I would argue, based on my flawed understanding of things, that it is less risky to have a C-section than a vaginal delivery…as long as you only do it once! Ah, nuance, you taste like candy :)

          3. Zoe says:

            I was actually thinking that too, or even more interestingly, Vbac. I’ve never seen a SBM post on that I don’t think. Will have to read All Natural too.

          4. Calli Arcale says:

            My late grandfather was for many years a general surgeon in a mid-sized North Dakota town. He told of one patient, a women whom he’d operated on several times. As a surgeon, he only delivered babies if things were going badly and they had to come out the via MacDuff route.

            Anyway, this particular woman was a good Catholic, and the last time he saw her, it was for her seventh baby. They had all been c-sections, because back then they did the vertical incision and that meant you did not get to try TOLAC because you’d split open. By that last baby, he could actually see the baby inside before he opened the uterus — the tissue had actually become translucent and it was a minor miracle it had held.

            I’ve had two c-section myself; last time, they had to open the uterus vertically because they couldn’t pull her out through the transverse incision that they’d started with (which means my intended TOLAC would probably not have gone very well — we did the second c-section because she was breech, and the combination of breech plus past c-section meant no way were they gonna let me try pushing; good thing, too, since on top of all that, we also discovered she had the cord wrapped around her neck and she had to be resuscitated when they got her out). I have no intention of becoming pregnant a third time. Both of my c-sections went extremely well, and I was up and about the next day, with no serious problems getting breastfeeding established. But the risks climb with each pregnancy. I’m done.

            1. Chris says:

              “we did the second c-section because she was breech, and the combination of breech plus past c-section meant no way were they gonna let me try pushing; good thing, too, since on top of all that, we also discovered she had the cord wrapped around her neck and she had to be resuscitated when they got her out)”

              :-o Oh, my.

              On retrospect my first should have been a C-section. He had his father’s huge Dutch head, which is why he became stuck. Though there is no way to connect that to his neonatal seizures (induced labor at 42 weeks was six hours, the last ninety minutes were pushing with forceps assist).

              Fortunately, the other two have “mom-shaped” heads, and slipped out quickly. As my step-sister says: “the skids were greased” (also she was denied an epidural for her second child because there was meconium in the amniotic fluid for her first).

              The risk for me kinda went down for each pregnancy. The second labor was four hours, the third was two hours. I was only notified of the real labor by my water breaking. I figured if I had a fourth it would have been involuntarily at home.

              Hence the hubby getting snipped. What really nailed it were the several breast infections from child who refused to become weaned, and the back going out due to getting her in and out of the car seat. Well, I was in my late thirties when I had her.

              Yeah, yeah, yeah… we had a third because we wanted a girl. A child who turned out to cause more trouble than both of her brothers put together!

              Dear young folks who want kids: crawling, walking and talking early is not a good thing. There is this thing that lags: common sense. Plus it does not help when older siblings do not close stair gates when you have a walking nine month old. I would start to cook dinner and turn my back on the baby who is engaged in some toy, only to hear her giggling as she was climbing the stairs!

  8. Vicki says:

    I think “an engaged patient [versus] someone who does what they are told” is a false dichotomy, for two reasons. One is that the more-engaged patient is more likely to tell the doctor about all the relevant factors, rather than one specific symptom or problem.

    The other reason is that, given the same diagnosis and the same prescribed treatment, the engaged patient is more likely to in fact take the doctor’s advice, whether that means taking the entire course of antibiotics, keeping water out of their ear, or calling a physical therapist and then doing the prescribed exercises. But it’s hard to tease out the patients for whom physical therapy wouldn’t work in any case from the ones who didn’t actually do the exercises as prescribed; they both turn up back at the orthopedist looking for a steroid shot.

    1. Windriven says:

      “I think “an engaged patient [versus] someone who does what they are told” is a false dichotomy…”

      I think you entirely missed Zoe’s point.

  9. Thor says:

    The mother of my son was primed and prepared to have a home water birth, not just laboring in water, but the birth itself. She had two ‘competent’ midwives at her side. Didn’t go according to plans, though. After laboring for 19 hours (yes, it took that long due to CAM blinders about the reality of the situation), she was rushed to the hospital and had an emergency C section—the cord was wrapped around the fetus’ neck three times! It could easily have ended disastrously; in another time period both mother and baby would have died. So much for the naturalistic fallacy. And this alternative approach to giving birth.
    Funny thing is that this complication actually prevented my son from potential unforeseen circumstances of underwater birth. What irony, and puts this discussion into bright perspective.

  10. Vicki says:

    Apparently I did. Could either you or she please restate it/point me at what I have missed? Telling me that I missed the point hasn’t clarified it: yes, Zoe gives examples of well-informed patients who asked a lot of questions and says that her doctors were happy with that, but “others here I’m not sure” implies that not everyone is as accepting of the questioning patient as Drs. Hall and Gorski, or the doctors she has been fortunate enough to have.

    I am not doubting that Zoe has consistently had good doctors, but neither do I doubt my friends and acquaintances who report doctors who were far from patient with being asked why they were prescribing X medicine or Y treatment, or the ones whose *doctors* were so far from engaged that they didn’t even address the presenting complaint.

    1. Zoe237 says:

      Vicki, I don’t recall your specific argument, but I definitely believe there are doctors who want patients to shut up and do what they say, all the way to doctors who go too far in the other direction, and everything in between. I also believe that historically speaking, in childbirth, mothers wishes were routinely ignored for all sorts of, many times sexist, reasons. There’s a balance there, pros and cons. I was just surprised that many don’t see, to understand that of course the birth of a child is an experience, not just a medical procedure. Yes, we should be happy to be alive after, but it’s a day the mom will remember forever. Was she treated like a human being or a vessel for a child? I’m not sure it’s the OBs place to try to convince the mother to use or not use pain medication, but simply to make it available.

      1. Windriven says:

        @Zoe

        “I’m not sure it’s the OBs place to try to convince the mother to use or not use pain medication, but simply to make it available.”

        It is perfectly reasonable for an OB to lay out the pros and cons from his or perspective. It is even reasonable for an OB to refuse to do non-epidural deliveries – so long as that is made clear up front. The patient has every right to have her reasonable preferences accommodated. OBs have every right to practice medicine as he or she sees fit. That simply means that some doctors and some patients aren’t a good match. But it is absolutely unacceptable for either party to withhold important information until labor is well underway.

        1. Harriet Hall says:

          “It is even reasonable for an OB to refuse to do non-epidural deliveries”

          I disagree. Have you ever heard of an OB doing that? I can’t think of any credible reason for an OB to refuse to do non-epidural deliveries. I did my first deliveries back in 1970, and even back then, we routinely asked the patient whether she wanted to labor with or without pain relief. Many opted for natural childbirth a la Dick Read. I never heard of a doctor trying to convince a mother either way. Twilight sleep was “out” by then, and epidurals were not yet “in.” We offered saddle blocks or paracervical/pudendal blocks for the delivery itself, and most patients gladly accepted one or the other, but sometimes a delivery was too precipitous to allow time to administer them. We never sewed up an episiotomy or a spontaneous tear without some kind of analgesia, a local anesthetic in the case of precipitous delivery. I am sorry to say we routinely did episiotomies because the evidence at the time suggested it was safer for mother and baby; as an intern I was severely chastised by the attending staff physician when I omitted an episiotomy in a grand multipara who begged me not to do one and who definitely did not need one. Subsequently, better evidence showed routine episiotomies were not necessary, and they are no longer done.

          I chose an epidural for my own first delivery, but I did not get one for the second because there was no one in the hospital at the time who was trained to administer them. In both cases, I had excellent pain relief, and no one tried to influence my choices in any way. They even gave me the choice of a birthing room or a delivery room; I chose the delivery room because I had never set foot in a birthing room but had delivered hundreds of babies in delivery rooms and felt comfortable in that environment.

          Do OBs have the right to practice medicine as they see fit? Yes, but they also have the obligation to avoid harming their patients. For instance, if they have no expertise in breech deliveries, they can and should do a C-section. And they don’t have the right to deny the personal preferences of their patients unless there is a compelling reason. If some OBs refuse to accommodate the reasonable preferences of their patients, I am fortunate enough never to have run across one of them.

          1. Windriven says:

            “Have you ever heard of an OB doing that?”

            Absolutely. My then wife wished to do ‘natural’ childbirth and was told by one physician that he would not be willing to participate. As I recall he had a bad experience early in his practice and preferred a setting where he felt more in control (my words not his). Neither my wife nor I were particularly upset as he was frank about it from the beginning. She chose a different OB who was very supportive and had three good experiences (including a 10 pound 2 ouncer that scared the crap out of all of us during delivery).

            A note between us pre X-gens: Do you remember the days of the penthrane pipe? There were still a few rural hospitals in the south that used them as late as the very early 80s when I got my start in the devices business.

            1. Harriet Hall says:

              You originally said non-epidural deliveries; did you mean to say natural childbirth? Surely that doctor didn’t insist on doing an epidural on every patient. Surely he knows that some women deliver precipitously and some experience little or no pain at all: it would be unethical to arbitrarily insist on epidurals for them. I am appalled that he refuses to attend natural childbirth based only on “a bad experience” and a need to feel more “in control.” That’s far from a science-based attitude, and I would argue that he is acting in his own interest and not in the best interests of mother and child.

              1. windriven says:

                No, this physician’s objection specifically included not having an epidural and in fact all that ‘natural’ childbirth amounted to in my former wife’s context was no epidural and use of a birthing room in the hospital.

              2. windriven says:

                “That’s far from a science-based attitude, and I would argue that he is acting in his own interest and not in the best interests of mother and child.”

                He was certainly acting in his own interest but also, right or wrong, cast it in terms of the best interests of mother and child.

                There are all sorts of physicians out there. It can be trying and expensive to find one whose approach works well with your own. I had a good deal of difficulty finding an internist who was science based, collaborative, and willing to spend the necessary time with me. For people who are paid by the hour or have limited financial means, that search can be impossible.

    2. Windriven says:

      @Vicky

      It is probably presumptuous of me to speak for Zoe. But I took her point to be that engaged patients who understand not only what the prescribed treatment is but also understand why this is the best alternative are likely to be more compliant and less likely to seek alternatives from quacks.

      Ignorance, powerlessness, and fear are powerful emotions that leave one diminished and unhappy. Knowledge, control, and clarity – even when they point to a final outcome that is likely to be terminal – maintain agency and dignity.

      Madison MD touched on this recently and I wish I could find the comment now to point you toward.

      But you are quite right to note that some physicians are turds. A physician friend of mine pointed out to me that once you’re through med school you get an MD. You might have graduated last in your class, been last pick for a residency and have the bedside manner of a cockroach. You can’t tell until you start exploring, probing, and digging. The time to start is not when your life is hanging in the balance. Find a primary care physician with whom you connect and with whom you can communicate openly and honestly. When the sh!t hits the fan you are going to count on her or him to make referrals and, if you’ve built the right relationship, be your advocate and translator if necessary. Specialists will be far more likely to see you more as a diagnosis and treatment plan than your PCP.

      I guess the message (mine, at least) is that your life is your responsibility. You cannot ethically abdicate that responsibility and then claim you’re being treated badly. The physicians that you hire are highly trained technicians and scientists. You need and should embrace their expertise. But if you are given good cause to doubt their expertise, their commitment, or their willingness to communicate honestly and completely it is time to do the Donald Trump thing.

  11. Zoe237 says:

    “It is perfectly reasonable for an OB to lay out the pros and cons from his or perspective. It is even reasonable for an OB to refuse to do non-epidural deliveries – so long as that is made clear up front. The patient has every right to have her reasonable preferences accommodated. OBs have every right to practice medicine as he or she sees fit. That simply means that some doctors and some patients aren’t a good match. But it is absolutely unacceptable for either party to withhold important information until labor is well underway.”

    I also can’t think of a good reason to refuse to deliver a child naturally. I guess I’d rather know upfront if they aren’t supportive though, because having the ob second guess your neutral choice when you’re in labor is too hard. I agree with laying out the pros and cons of using pain medication, but not “convincing” either way. I definitely agree with a “wait and see approach” to pain relief. I did that with my wisdom teeth removal (only a local, drove myself home), my two ACL reconstructions / meniscus removal (Percocet for a few days, went back to work after four days), and childbirth (three no medication, went back to school part time after two days). I just don’t see why both sides are either 1. People who have an epidural failed to win the Ncb medal, Or 2. People who don’t have an epidural are falling prey to misogyny or a naturalistic fallacy.

    I hadn’t read the acetaminophen article and the ensuing comments until yesterday. There are some interesting parallels there.

    1. Young CC Prof says:

      Actually, there are reasons that a doctor MIGHT insist on an epidural for some births, although not all.

      If your doctor believes you are at significant risk of needing emergency caesarian or another intervention that can’t be performed without anesthesia, having the epidural already placed can save minutes, which translates to maybe saving lives. So for high-risk deliveries, the doctor may very strongly recommend a pre-placed epidural.

    2. Sean Duggan says:

      While I don’t know if it would really count as good grounds, I could theoretically see such a refusal as being the result of a bad experience with someone who refused the epidural and then proceeded to cause trouble for the hospital either because they changed their mind on whether they’d actually told the doctor to skip the epidural (written contracts might help with that, of course) or because they developed health complications (broken blood vessels from straining, blood pressure issues from stress, etc) which they later claimed the doctor should have been aware of. As others have said, does it matter if they’re up front about it?

  12. Colin Davis says:

    Since this is an American website, I am surprised that everyone seems to be ignoring the influence of religion. Doesn’t the Bible say that women suffer the pains of childbirth as a punishment for the sins of Eve? For an uncomfortably large number of Americans (if the polls are anything to go by), that would be quite sufficient to brand those epidurals as “wrong” and contrary to God’s will.

    1. windriven says:

      @Colin Davis

      An interesting point. I have never heard of someone refusing an epidural for that reason. But nothing would surprise me anymore.

    2. Harriet Hall says:

      Most religions (in America and elsewhere) do not advocate that women forgo pain relief in childbirth. There are exceptions (faith healing sects, Christian Science) but they are only a small minority. The attitude was prevalent in the UK until Queen Victoria set an example by using chloroform for the deliveries of a couple of her children. Logically, even if Eve’s sin is the reason childbirth is painful, that doesn’t necessarily mean that it is wrong to relieve the pain for her descendants.

      1. mouse says:

        It’s certainly not a common Christian approach. There are small Christian sub-groups, such as the Quiverful followers who advocate unassisted home births. You can google it.

      2. Windriven says:

        “[E]ven if Eve’s sin is the reason childbirth is painful, that doesn’t necessarily mean that it is wrong to relieve the pain for her descendants.”

        I wonder if Ken Ham and his ilk would agree or if they would argue that an epidural would thwart their god’s plan?

      3. Andrey Pavlov says:

        Logically, even if Eve’s sin is the reason childbirth is painful, that doesn’t necessarily mean…

        Except that when the fundamental premise is illogical, logic can mean whatever the person wants it to mean

        1. mouse says:

          I gotta agree with AP on this one. Although I will say that many Christians quietly go with logic over doctrine (eg the number of Catholics who use and or approve of birth control) In many cases logic does not appear to factor into the making of church doctrine. Although, it may…kinda depends upon the inclination of the clergy/decision makers and or the force of popular opinion in the congregation.

  13. Treetababy says:

    As a woman who had a midwife attended, low-risk, water birth at a water birth center I have to admit it was an experience my sister’s who had hospital c-section births envy, primarily because they were NOT given any choices. I had switched care from at hospital OB-GYN setting at 28 weeks because the woman doctor I chose was also pregnant and told me she would not be able to attend my birth and she did not know who would – it would be whoever was on call that day. That was the last I that hospital. My husband was a second child born at home with a midwife and his father as per the British system in 1971. HE was the one to encourage me to go to see the midwives and water birth center. The first thing I did is research and watched A LOT of youtube water birth videos, the more I watched the more I was convinced that was the kind of setting I wanted. No shaving, no episiotomies, no drugs – just me and trusting my body to do what I knew it capable of doing.

    I had a backup emergency plan if necessary – the water birth center is across the road from a hospital.

    I had my first and only baby 8lbs13oz, no tearing, no problems.

    I was fully informed of the risks from both my OB-gyn when I went to her and again when I entered the care of the midwives – whom work closely with doctors and nurses as needed even though they are a separate entity from the hospitals.

    I believe as the pendulum swings away from forced procedures to more choices in childbirthing, it will center some will be quite happy in the hospital settings and some will choose a more personalized/ homebirth setting. The task will be to offer safe alternative choices.

    One last thing I suggest – that I didn’t see mentioned is Ricky Lake’s documentary “The Business of Being Born” I watched after having my daughter, but had come to most of those same conclusions.

    1. Harriet Hall says:

      I covered “The Business of Being Born” back in 2008. See http://www.sciencebasedmedicine.org/the-business-of-being-born/

      You say you chose water birth because there was “no shaving, no episiotomies, no drugs.” But you don’t have to choose water immersion or home birth to avoid those. Conventional obstetrics no longer involves shaving or routine episiotomies, and it has never “required” drugs. It has become far more responsive to women’s choices. Home-like birthing rooms and nurse-midwives have been integrated into conventional obstetrics at many hospitals, combining the best aspects of both philosophies.

      1. Treetababy says:

        Harriet Hall,

        My daughter is several years old now, and when I went to my ob-gyn at a large hospital in Portland, Oregon. Some choices were given to me, but I had to spell it out and ask all the while my Dr was looking at me like I was a lunatic – which I am not. Two major points were why I chose to birth outside of the hospital setting.
        1. Not knowing my caregiver/ person delivering my baby, seeing me and helping me at my most vulnerable – would not be a stranger and as it was turning out that is exactly what was going to happen if I stayed. With the birth center I met with every (couple of weeks for almost hour long visits each) and had 2 midwives with 2 apprentices and they were with me and cared for me like a sister would – I can not explain to anyone in the medical (hospital) setting how much that meant to me – and I paid out of pocket to do this (my insurance wouldn’t cover it). That is the kind of care hospitals are VASTLY lacking (at least the one I was originally at).
        2. I had a viable, well thought out, researched, beautiful setting as an alternative, with an effective plan if need be if a problem should occur.

        By the way – they had many different birthing “position” options, many of which were not in water. I chose the water because while I was at home and my water broke in my hot tub 99F (it was the only place that I was comfortable in while I was in early labor) so when I finally arrived already naked and only in a robe in slippers – it was an easy transition to make. The buoyancy of the water allowed me to switch positions easily and without additional pain.

        I don’t believe the hospitals would have changed to accommodate women if women weren’t choosing to birth elsewhere, so yea they finally accepted women don’t want to be in a un-homey hospital room and want their choices respected.

        1. WilliamLawrenceUtridge says:

          I wonder if you, and the midwives, truly appreciate the speed with which low-likelihood, high-risk events can occur. Yes, most births could have taken place in the home. But if there is some major unexpected event such as a rupture of significant blood vessels during birth, would the time it takes you to cross the street from birth center (and to the appropriate floor, assuming the elevators are working) be less than the time it takes to exsanguinate? This might be why your doctor looked at you like you were a lunatic – because she had seen enough births that one of these events had happened to a patient in his/her care.

          I admit I would be extremely risk-averse in this circumstance. I would be horribly uncomfortable for the duration of the birth as I would be wondering if I would see an unrelenting gush of blood come out with the baby. I would also care far less about whether I knew the person delivering the baby, and more that they knew what they were doing and had the equipment to address any unexpected outcomes (which in birth centers they do have). I would also far prefer a “Dr. House” than a “Dr. Wilson” – someone who really, really knows what they are doing rather than someone who treats me nice (both fictionalized, and ideally without the hideous ethical violations).

          Different preferences, and while I would never advocate everyone adopt my preferences, nor would I advocate against people being able to adopt yours, I simply don’t understand them.

  14. Eric says:

    This article is polemic, plain and simple. I would thank the author to refrain from further slandering the name of science with such hateful menacing rhetoric. That is all :)

    1. simba says:

      Sooo.. what you’re telling us is you have absolutely no good evidence water birth is safe and effective.

      I mean, you can’t possibly think just saying ‘this article is polemic’ is going to change anyone’s mind, could you? If you had any well-reasoned argument or evidence, you’d bring it to the table and add it to that comment. Clearly you don’t.

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