This is point of inquiry for Monday, February 17th, 2014.
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Hello and welcome to Point of Inquiry, a podcast of the Center for Inquiry, a nonprofit dedicated to promoting science and secular values. I’m your host, Lindsay Beyerstein, and my guest today is Dr. Amy to her. She’s an obstetrician gynecologist and a former clinical instructor at Harvard Medical School after leaving the practice of medicine to raise her four children. She started a second career as a crusader for science in women’s health care. She blogs at the skeptical O.B., a site dedicated to exposing pseudoscience and misinformation in the natural childbirth and home birth movements. Well, it remains rare in absolute terms. Home birth is becoming more common. The home birth movement is led by self-styled certified professional midwives who claim to be experts in normal birth but who lack the education and training of certified nurse midwives in the U.S. or their counterparts in other advanced countries. Until recently, the leading accreditation body for certified professional midwives didn’t even require a high school diploma. The central dogma of the Homburg movement is that for properly selected women, home birth is just as safe as hospital birth manna. The Midwives Alliance of North America, a lobby group for midwives, has been collecting statistics from their members. The organization recently published an analysis of that data in the Journal of Midwifery and Women’s Health reporting to show that home birth is safe. Yet if you compare men as reported, baby death rate at home, birth to government stats on babies born in hospital, the infant death rate is 450 percent higher for home births. About two babies out of every thousand die at home birth compared to just point three eight babies per thousand in the hospital. Here to talk more about the study and its implications is Dr. Amy Tutor. Amy, welcome to the program.
So let’s start with a 30000 foot view of natural DANTRELL childbirth movement. Who are these people and what what in broad terms do they stand for?
The natural childbirth movement has existed for a number of decades, but it has become more popular over the last 10 years. And the home birth movement is an outgrowth of the natural childbirth movement with the philosophy that. If we creating birth in nature is worthwhile, then we should give birth at home or the home equivalent as animals do instead of in hospitals.
As an obstetrician, what would you say is is lacking in the view that birth isn’t inherently safe and should be undertaken at home?
Well, I think obstetricians have been the victims of their own success. It’s the hospitals in modern obstetrics that have made childbirth appear safe when in reality it’s inherently dangerous. We know in looking at historical data or even dead walking through cemeteries from the hundred, 200 years ago that they interpret natural rate of death in childbirth is very high, one percent for mothers and seven percent for babies. And we see that also in countries where modern obstetrics is not available. So the idea that childbirth is safe is an illusion. It’s only safe in the hospital with moderate obstetric interventions. Otherwise, it’s dangerous.
The maternal death rate for home births these days is not nearly one percent. Right? It’s better than at least better than that, right?
Well, the maternal mature childbirth has become so safe for women that maternal deaths are now measured per 100000, whereas 200 years ago they were measured per hundred. So the United States has raised the maternal death rate in the range of 10 to 13 per hundred thousand. Which is an awful lot better than a hundred per hundred thousand.
Definitely the natural childbirth movement and in many ways is can be situated within a larger context of anti scientific movements. Can you expand a little bit on that idea?
Yes. It seems to me that home birth is where the anti vaccine movement was about a decade ago. There was a belief that parents could educate themselves and disregard what were considered conventional authority figures. Doctors, epidemiologist, immunologist, because they were all hiding some secret about vaccines. And the home birth movement is pretty similar in that they believe that obstetricians and hospitals are hiding all sorts of secrets about birth and that they’re using fear to convince women to have give birth in the hospital in the same way that pediatricians and other public health officials used fear to convince parents to vaccinate. But as we know, if you don’t vaccinate. Deaths from vaccine preventable diseases begin to rise. And similarly, if you have a home birth, deaths from childbirth begin to rise.
Midwives play a big part in the natural childbirth scheme of things. Can you explain how they fit into the American way of birth?
Yes, well, the United States is the only country in the first world that has two kinds of midwives. We have certified nurse midwives, which are the most highly educated, most highly trained midwives in industrialized countries. They are nurses with a master’s degree in midwifery. They’re very well integrated into the contemporary medical system. I believe about 11 percent or more of all vaginal deliveries are performed by midwives. They work generally in hospitals. They can also work in birth centers. They have collaborative relationships with physicians. They are integral part of American obstetrics. On the other hand, we have certified professional midwives, which is a credential that a group of lay people awarded themselves. They are not required to have any kind of education and training. In fact, they, as of September 2012, strengthened their recommendations to require a high school diploma. They’re not allowed to practice in hospitals because they’re unqualified. And so they’ve taken to practicing at home and since home birth is the only thing they can do. They have very strong vested interest in promoting home birth.
So Intel 2012, they did not require a certified professional midwives, did not even require midwives to have a high school diploma.
Exactly. And certified professional midwives and and their leadership, like Melissa Cheney in Oregon, who’s the head of Direct Entry Midwifery Board in Oregon, actually campaigned for no requirements at all to be a midwife.
So literally, you could be a fourth grader, wake up one morning, call yourself a midwife, put up a website if you were in business. And the Oregon law up until recently mandated that the state could not penalized for that.
And this is very different than countries like the Netherlands or Canada that are sometimes held up as examples of how home birth midwifery can work. Correct.
Correct. Because the midwives in Canada, Australia, the Netherlands, the U.K., they are the equivalent of certified nurse midwives in this country. Every midwife in every other industrialized country has a university level degree in midwifery and extensive in hospital training. And that training includes diagnosing, preventing and managing complications. To give you some idea of the differences between the two types of midwives in the United States, the certified nurse midwife credential is accepted in other countries. The certified professional midwife self awarded credential is accepted Deleware.
One of my favorite activity on your blog is pointing out pseudoscience and the rhetoric of CPM is what? What are some of the real howlers that you guys have been discussing lately, beliefs that stand out to you as being anti science or just flat out incorrect about the physiology of childbirth?
Well, I think that the paradigmatic example of pseudo science in childbirth is a article that appeared in the Australian Midwifery Journal, I believe, in 2009 or 2010. And it was entitled Using the Non Rational is sensible midwifery. And it includes a section on how to treat women who were suffering from postpartum hemorrhage, which is excessive bleeding after the baby is born. And it’s suggested calling the mother’s body to stop bleeding.
Among one of the techniques you’ve been just asking nicely.
Well, I think it was more begging, nicely effort, but I think it is hard to believe that that could be published anywhere.
But it gives you some idea of what’s gone on in contemporary natural childbirth circles. You know, one of the people who’s been extremely influential is Myname Gaskin. And she was one of the people who created the CPM credentials so she could award it to herself. And I’m donating asking this what philosophers would call the feminist anti rationalist. She’s one of the people that believes that. Science and mathematics and even rational thought are patriarchal remnants from our oppression under Mitt.
And that women have other ways of knowing. There are a number of feminist philosophers that have also. Define this kind of philosophy. But if you believe that science. Is just one way of knowing and that intuition is just as good. Well, you’re going to believe a lot of crazy things that aren’t true.
And it’s kind of interesting, there’s this sort of two IT ness of this movement where on the one hand they want to say we can compete on evidence based medicine alongside the obese. And then there’s this countervailing trend of who needs science and rationality anyway.
I think that the natural childbirth movement and the home birth movement has a habit of cycling through means. The original meme was recently decreed in the 1930s that childbirth pain is caused by fear. And there are some people who still believe that.
But another mean that has been particularly successful for natural childbirth advocates is the idea that obstetricians will follow scientific evidence and midwives do. And they just made that up. There’s there’s absolutely no evidence of that. And if you really think about it, it doesn’t make any sense, because obstetricians are the people who.
Discover the scientific evidence and they write about it and they publish it and they compete with each other to get more evidence and to undermine each other’s evidence. And there are literally thousands of Detrich scientific journal articles that are published every single month. So it really stretches credulity to believe that the people who do the research are ignoring the research, while the people who do know research are supposedly assiduously reading all these thousands of articles every month and constantly reevaluating their practice and incorporating these things into their practice.
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There’s a meme that seems to be really durable, I don’t know if it originated in the Ricki Lake documentary, The Business of Being Born. But this idea of a cascade of interventions.
Can you elaborate on what that is and what basis, if any, that has, in fact, the cascade of interventions had some basis in truth in the sense that obviously, if you do nothing, you end up going to end up doing nothing. And the minute you do a test, you’re going to you may end up doing more things. So, for example, if you check people’s blood pressure, just regular people, you know, not pregnant women. Have you checked their blood pressure? And you find it high, you’re going to treat it. And if you treat it with one medication and it’s still high, you might add a second medication. And so you’ve gone into the, quote, unquote, cascade of interventions. But when we treat people’s high blood pressure, we don’t look at the interventions as bad. I mean, if we can replace them with easier things like diet and exercise, that’s terrific. But if we can’t, we take the medication. The problem is that. The interventions that natural childbirth and home birth advocates are talking about are interventions that they themselves cannot perform. And therefore, they’ve demonized them. That’s the reason for the demonization of CSX. I assure you that if Widmaier could build for these actions all this and they’d be terrific, but they can’t.
And so therefore, they’re bad. Midwives can’t offer epidurals all of a sudden they’re bad.
They tell women to go for cranial sacral therapy, which doesn’t even work. But that’s an okay intervention. So the testing them interventions. Yes, it’s true. You know, if you don’t take a temperature, you won’t find a fever. But when somebody’s sick, we want to know if they have a fever. And when somebody is in labor, we want to know if the baby’s and getting enough oxygen is there. And it’s absolutely true that if you check to see if the baby’s getting enough oxygen, there’s going to end up being more interventions than if you never checked. But there’s also going to end up being less deaths.
Is it is is there any truth to the idea that if you give Pettersen to speed up labor, that it does or you have an epidural, that this somehow makes it more causally likely as a kind of side effect that a C-section will become medically necessary?
Well, you know, it’s the difference between correlation and causation. When you give somebody pitocin to augment their labor, the reason you do it is that their contractions aren’t strong enough. And therefore, if you make their contractions strong enough to be effective, they’re more likely to unmask the problem with the placenta. The baby not getting enough oxygen. Then if the contractions are weak and ineffective. Pitocin is just meant to simulate natural labor, and it’s not given to everybody. It’s only given to people who demonstrate a need for it. So are there more interventions for women who get to telson? Of course there are. Because they got it in the first place because something was wrong.
So tell us about the manner of a midwifes alliance of North America and what they modestly deem a landmark new study about the safety of home birth, that they’re claiming that this shows that home birth is safe. Having the study, what does it actually show?
Well, you know, the ironic thing is the Midwives Alliance with North America study shows exactly the same thing as all the other studies that show home birth isn’t safe. The only difference between their study and studies done by obstetricians is that the Midwives Alliance of North America lied about what their data showed. So if you compare their study to some of the recent studies that came out of court now. Or other places you find that home birth increases the risk of death by anywhere from four to nine times compared to. Hospital birth for similar risk women.
And the death of the baby, right?
That’s the death of the baby. Exactly. If you look at the data from the midwives of Alliance of North America publication, you find that their death rate, which they acknowledge was two point zero six per thousand births, you find that that is 5.5 times higher. Four hundred and fifty percent higher than what the CDC has calculated, the death rate to be in the hospital for those years. Now, the Midwest alliance with America did a sneaky little thing. They didn’t mention the CDC data. They compared they their data it anything but the appropriate comparisons because they knew that the appropriate comparison showed their death rates to be hideous. And now that High and others have come forward to point out this attempt to trick people, they’ve resorted to, you know, I wish we tend to want to sugar coat or euphemize language, but in this case, I mean, I really have to say they are why? They are absolutely like they.
This is the part where they’re saying that the CDC number is somehow not accurate. Correct.
And they have relied upon the numbers from the CDC for years. I have publications from both the Midwives Alliance of North America and the American College of Nurse Midwives dating back. Eight years in which they constantly invoke these numbers for a variety of reasons.
And these are data where they’re match, where the CDC is matching birth certificates and death certificates. Right. So it’s a pretty hard data that, yes, this baby was born and yes, it died and where it was born and where it was intended to be born.
Right. Well, one of the things that the midwives lines of North America has said is that these weird certificates are unreliable for place of birth. And it is true that prior to 2003, when there was no place on the birth certificate to list place of birth birth certificates could be pretty unreliable for that data. But once you start talking about 2003 and after. There’s a place on the birth certificate to say where the baby was born. And the law is that all American birth certificates must be signed by the person who actually delivered the baby. If a birth certificate says that the baby was delivered at home and a home birth midwife delivered that baby. There’s really no way that that was an accidental out of hospital birth. Absolutely no west. And in fact, the statisticians from the CDC, including Marion McDormand, who has been criticizing the birth certificate data, they actually used it in a variety of studies to show that the home birth rate was rising. So in Mana and the American College of Nurse Midwives publicize those findings. So evidently it was accurate. Back when it showed that home birth rates were rising. But now that it shows that in those rising rates are lots of deaths. Suddenly we’re supposed to believe it’s inaccurate.
And the new study is based on information that was gathered by a self selected group of Manam members. Right.
Well, you know, the thing is, it’s not even really a study. We talk about it that way. And even I talk about it that way to use in in shorthand, because that’s the way people think of it. But it really is a non random survey.
The Midwives Alliance of North America has told their midwives to submit. The results of all their births. What happened is somewhere between 70 and 80 percent of the midwives refused to participate. And then of the remaining 20 to 25 percent. Something like a quarter of those did not send in the data for all their deliveries. Only some of it. So this is a you know, it’s a survey. The nonrandom survey kind of like, you know, if you go on NBC News dot com and you vote for it, which president you would person you think should be elected. And they warn you that this is a nonrandom survey. It’s the same exact thing. And which makes it even more chilling that even though a lot of Midways didn’t participate in even though the midwives who participated didn’t include all their statistics, the numbers are still terrible.
Did they do any kind of real life checking? I mean, they talk in the paper about how they check their statistical methods to make sure they keyed in the data correctly. But did they pull any charts or call any patients or find any. Yes. Certificates of their own to actually establish that the cases reported by their responders were now and now the way they said they happened?
Absolutely not. There’s no there’s been no checking for accuracy. But you have to figure that it’s not likely that the midwives made up deaths. So the deaths they earned about those were real. And there were probably others that aren’t even included. So the real numbers, I would guess the real numbers are range of the death rate of about 10 times higher than comparable risk. Hospital births. And that’s just what the midwife, Judith Rook’s found when she looked at Oregon’s data. She was asked to do so by the state of Oregon. And she’s a certified nurse midwife with a masters of public health. And she had access to the birth certificate. And I believe she had access to the records as well. The hospital records and she found a death rate nine times higher among home birth midwives. So. You know, the the ironic thing is the data is all consistent. It all shows that home birth increases the risk of death. The only difference between what mom did and what everybody else did is that they lied about what the data actually shows. Their data is the same.
The idea that your baby could be up to 10 times more likely to die at home birth than in the hospital is a sobering thought.
Even if the absolute risk of death remains relatively low, it is pretty stunning and it’s something that every woman deserves to know. But I think that home birth is the sort of the new virus in the sense that. Women are patients are not getting accurate information about the dangers. And I think people forget that Vioxx, which was ultimately pulled from the market for the deaths that it caused. It worked. It provided good pain relief for people. It was just that tiny problem that a lot of them or not not even a lot. But some people died and they hadn’t been told that that could be a side effect. And the drug company worked really, really hard to make sure that people didn’t find out about it. And when other researchers. Published papers that showed that Vioxx caused heart attacks and strokes. The drug company was out there discrediting them by saying just about anything they could think of to say don’t look at that research, look at our research and hope that this kind of the same way that every woman has a right to have a home birth. But every woman has a right to accurate information. And the only product that the midwives long alliance of North America is selling his home birth. And they’re the only people telling everyone that it’s safe. And they are the only people running around trying to discredit the vast majority of studies which were not done by them. Which shows that it’s dangerous. So. I think the consumer really, really has to be aware of the the risk that the midwives, the of North America is hiding the truth because they’re afraid that the truth will scare off business.
Dr. Amy, thank you so much for sharing your analysis with us today.
My pleasure. Thank you.
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