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Midwives and the assault on scientific evidence

The new mantra of midwives and their advocates is “evidence based practice.” Lamaze, the childbirth education organization has changed the name of their blog to “Science and Sensibility” emphasizing the importance of science and promising:

Lamaze education and practices are based on the best, most current medical evidence available, and can help reduce the overuse of unnecessary interventions while improving overall outcomes for mothers and babies.

But midwives and childbirth educators like Lamaze have a problem. The scientific evidence often conflicts with their ideology. They could address this problem in several ways. Midwives could modify their specific ideological beliefs on the basis of scientific evidence. Childbirth educators could question whether ideology has had an inappropriate impact on the promulgation and validation of their recommendations. Both those approaches would involve a threat to cherished beliefs. They, therefore, have taken a different approach. They’ve tried to justify ignoring scientific evidence.

As midwives Jane Munro and Helen Spiby have documented in The Nature and Use of Evidence in Midwifery, the first chapter of their book Evidenced Based Midwifery, midwives were initially enthusiastic about basing clinical practice on scientific evidence. That’s because they had long told each other that midwifery was “science based” while obstetrics was not:

At the beginning of the evidence based practice movement, much of the midwifery profession responded enthusiastically to the potential for change… Evidence based practice was seen to be offering a powerful tool to question and examine obstetric-led models of care that had dominated the previous decades. The results of such examination could have meant ‘starting stopping’ the unhelpful interventions that had embedded themselves in common practice …

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A critique of the leading study of American homebirth

Its authors boast that it is one of the ten most downloaded papers from the British Medical Journal (BMJ). That makes it even more unfortunate that the conclusions of the paper are directly at odds with the findings of the paper. Outcomes of planned home births with certified professional midwives: large prospective study in North America by Kenneth Johnson and Bettye Ann Davis is the premier paper on the safety of American homebirth. It claims to show that homebirth is as safe as hospital birth, but actually shows that homebirth has nearly triple the neonatal death rate of hospital birth for comparable risk women.

Johnson and Daviss, in collaboration with the Midwives Alliance of North America (MANA), the organization of American homebirth midwives, collected data on all homebirths attended by Certified Professional Midwives (CPMs, homebirth midwives, as distinct from CNMs, Certified Nurse Midwives) in the year 2000. Then the authors compared the outcomes for interventions and for neonatal deaths with a hospital group.

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

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

They used singleton, vertex births at 37+ weeks as a proxy for low risk women. They found, not surprisingly, that intervention rates are lower for homebirth. Then they turned to neonatal mortality rates. They should have compared the neonatal mortality rate of the homebirth group to the neonatal mortality rate of the hospital birth group, but they did not. Instead, they compared homebirth deaths to hospital births in a variety of out of date studies extending back more than 20 years.

The authors conclude:
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Does C-section increase the rate of neonatal death?

It is a potentially devastating indictment of the rising C-section rate. Most midwifery and “natural” childbirth websites claim that elective C-section triples the rate of neonatal mortality. Mainstream web sites like Feministing.com, and newspapers like The New York Times have repeated the claim. There’s just one problem. It’s not true.

The claim originated with the paper Infant and Neonatal Mortality for Primary Cesarean and Vaginal Births to Women with “No Indicated Risk,” United States, 1998–2001 Birth Cohorts, MacDorman et al, Birth Volume 33 Page 175, September 2006. According to the authors:

Neonatal mortality rates were higher among infants delivered by cesarean section (1.77 per 1,000 live births) than for those delivered vaginally (0.62). The magnitude of this difference was reduced only moderately on statistical adjustment for demographic and medical factors, and when deaths due to congenital malformations and events with Apgar scores less than 4 were excluded. The cesarean/vaginal mortality differential was widespread, and not confined to a few causes of death. Conclusions: Understanding the causes of these differentials is important, given the rapid growth in the number of primary cesareans without a reported medical indication.

The implication, of course, is C-sections done without a medical indication raises the risk of neonatal death by a factor of three. The entire study hinges on a critical detail. Are women with “no indicated risk” really women who have no risk factors? The answer is a resounding no.

Since birth certificates are such an important source for research information, they have been repeatedly studied for accuracy. Birth certificates are highly accurate for administrative data like parents’ names or numerical data like weight or Apgar scores. It is well known, however, that they are highly inaccurate when it comes to listing complications.
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What’s in the water at waterbirth?

Waterbirth has been touted as an alternative form of pain relief in childbirth. Indeed, it is often recommended as the method of choice for pain relief in “natural” childbirth. It’s hardly natural, though. In fact, it is completely unnatural. No primates give birth in water, because primates initiate breathing almost immediately after birth and the entire notion of waterbirth was made up only 200 years ago. Not surprisingly, waterbirth appears to increase the risk of neonatal death.

Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey was published in the BMJ in 1999. Out of 4,030 deliveries in water, 35 babies suffered serious problems and 3 subsequently died. It is unclear if any of the deaths can be attributed to delivery in water. However, of the 32 survivors who were admitted to the NICU, 13 had significant respiratory problems including pneumonia, meconium aspiration, water aspiration, and drowning. Other complications attributable to water birth include 5 babies who had significant hemorrhage due to snapped umbilical cord. In all, 18 babies had serious complications directly attributable to waterbirth. The risk of serious complications necessitating prolonged NICU admissions was 4.5/1000.

Hospitals in Ireland suspended the practice of waterbirth after a baby died from freshwater drowning after delivery in a waterbirth pool.

The most nonsensical aspect of waterbirth is that it puts the baby at risk for freshwater drowning. The second nonsensical aspect is that the baby is born into what is essentially toilet water, because the water in the pool is fecally contaminated. In Water birth and the risk of infection; Experience after 1500 water births, Thoeni et al. analyzed the water found in waterbirth pools both before and after birth. The water in a birth pool, conveniently heated to body temperature, the optimum temperature for bacterial growth, is a microbial paradise.
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“The mother is the factory”

Who said: “the mother is the factory, and by education and care she can be made more efficient in the art of motherhood”?

That was written in 1942 by Grantly Dick-Read, widely considered to be the father of modern natural childbirth. Most people don’t realize that natural childbirth was invented by a man to convince middle and upper class women that childbirth pain is in their minds, thereby encouraging them to have more children. Read’s central claim was that “primitive” women do not have pain in childbirth. In contrast, women of the upper classes were “overcivilized” and had been socialized to believe that childbirth is painful.

In Holistic obstetrics: the origins of “natural childbirth” in Britain, O Moscucci, PMJ 2003;79:168-173, Dr. Ornella Moscucci explains the backdrop against which the philosophy of “natural” childbirth was promulgated:

Health policy became the subject of intense public debate in the aftermath of the Boer war, when Britain’s near defeat at the hands of a barely trained army focused the attention on the physical fitness of new recruits… Adherents to the new science of eugenics on the other hand blamed heredity. In their view, health policy should aim to prevent reproduction among “low quality” human stock .., and encourage reproduction among “good” stock…

The development of “natural childbirth” owed much to the activities of physicians and health professionals who were in sympathy with the aims of reform eugenics…

[T]hese health reformers were concerned about the differential birth rate—the tendency of poorer, less healthy sections of society to have larger families than their “betters”. Thus, as well as endorsing plans for the sterilisation and detention of “degenerates”, they also sought to encourage the middle classes to have more children… Female education and employment were seen as a particular evil, insofar as they led women to regard motherhood a burden and to neglect hearth and home…

One obvious way to reverse the falling birth was to entice women of “superior stock” back into the home, where they would fulfill their functions as wives and mothers. Health reformers took up the challenge by developing an ideology of childbirth that emphasised the “naturalness” of pregnancy and birth. This ideology functioned at a number of levels. It was prescriptive, in that it rooted woman’s social role in her biological capacity for reproduction… Motherhood was not only a woman’s supreme fulfilment and reward, but also her civic duty…

Read himself stated:

“Woman fails when she ceases to desire the children for which she was primarily made. Her true emancipation lies in freedom to fulfil her biological purposes”..

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What’s the right C-section rate? Higher than you think.

Editor’s Note: Dr. Mark Crislip has been kidnapped by anti-vaccinationists. Fortunately, we have sent our black Illuminati, pharma-funded, vaccine-wielding helicopters to rescue him, but unfortunately, as a result of his trauma, his usual Friday post is likely to be delayed either until this afternoon or Saturday. In any case, fortunately for us our latest addition to the SBM crew, Dr. Tuteur, was willing to fill in on short notice; so here she is. Dr. Crislip will post by tomorrow. To whet your appetite for his patented sarcasm, let me just say that he will be having a little fun with a certain article from The Atlantic about flu vaccines. There, now doesn’t that make you want to check back tomorrow to find out what his take is on the article? I thought it would.

Buried in the midst of it new report, Monitoring emergency obstetric care; a handbook, the World Health Organization acknowledges what obstetricians have been saying for some time. The WHO’s goal of a 10-15% C-section rate lacks any empirical basis.

Earlier editions of this handbook set a minimum (5%) and a maximum (15%) acceptable level for caesarean section. Although WHO has recommended since 1985 that the rate not exceed 10–15%, there is no empirical evidence for an optimum percentage or range of percentages …

Of course, they’re not going to give up their recommendation simply because there is no science that supports it, insisting that “a growing body of research that shows a negative effect of high rates.”

Dr. Marsden Wagner, former head of the Perinatal Division of the WHO, appears to be responsible for the purported optimal C-section rate of 10-15%, the level at which both maternal and neonatal mortality rates are supposedly the lowest. Ironically, Dr. Wagner is a co-author of a recent study that actually demonstrates the opposite.
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The Tragic Death Toll of Homebirth

More than 10,000 American women each year choose planned homebirth with a homebirth midwife in the mistaken belief that it is a safe choice. In fact, homebirth with a homebirth midwife is the most dangerous form of planned birth in the US.

In 2003 the US standard birth certificate form was revised to include place of birth and attendant at birth. In both the 2003 and 2004 Linked Birth Infant Death Statistics, mention was made of this data, but it was not included in the reports. Now the CDC has made the entire dataset available for review and the statistics for homebirth are quite remarkable. Homebirth increases the risk of neonatal death to double or triple the neonatal death rate at hospital birth.

As this chart shows, the neonatal mortality rate for DEM (direct entry midwife, another name for homebirth midwife) assisted homebirth is almost double the neonatal mortality rate for hospital birth with an MD. This is all the more remarkable when you consider that the hospital group contains women of all risk levels, with all possible pregnancy complications, and all pre-existing medical conditions. An even better comparison would be with the neonatal mortality rates for CNM assisted hospital birth. The risk profile of CNM hospital patients is slightly higher than that of DEM patients, but CNMs do not care for high risk patients. Compared to CNM assisted hospital birth, DEM assisted homebirth has TRIPLE the neonatal mortality rate.
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