Two links today for denialism blog readers, both are pretty thought provoking. The first, from Amy Tuteur, on the newly-released statistics on homebirth in Oregon. It seems that her crusade to have the midwives share their mortality data is justified, as when they were forced to release this data in Oregon, planned homebirth was about 7-10 times more likely to result in neonatal mortality than planned hospital birth.
I'm sure Tuteur won't mind me stealing her figure and showing it here (original source of data is Judith Rooks testimony):
Armed with data such as these, it needs to become a point of discussion for both obstetricians and midwives that out of hospital births have a dramatically-higher neonatal mortality, and this is worse for midwives without nursing training (the DEM or direct-entry-midwives). It's their body and their decision, but this information should be crucial to informing women as to whether or not they should take this risk. It also is only a reflection of neonatal mortality, one could also assume it speaks to higher rates of morbidity as well, as longer distances and poorer recognition of fetal distress and complications will lead to worse outcomes when the child survives. It should be noted this data is also consistent with nationwide CDC data on homebirth DEMs, and actually better than midwife data for some states like Colorado.
The second article worth pointing out today (even though it's old) is from Michael Shermer in Scientific American on the liberal war on science. Regular readers know that I'm of the belief there isn't really a difference between left and right-wing ideology on acceptance of science, it just means they just reject different findings that collide with their ideology.
The left's war on science begins with the stats cited above: 41 percent of Democrats are young Earth creationists, and 19 percent doubt that Earth is getting warmer. These numbers do not exactly bolster the common belief that liberals are the people of the science book. In addition, consider “cognitive creationists”—whom I define as those who accept the theory of evolution for the human body but not the brain. As Harvard University psychologist Steven Pinker documents in his 2002 book The Blank Slate (Viking), belief in the mind as a tabula rasa shaped almost entirely by culture has been mostly the mantra of liberal intellectuals, who in the 1980s and 1990s led an all-out assault against evolutionary psychology via such Orwellian-named far-left groups as Science for the People, for proffering the now uncontroversial idea that human thought and behavior are at least partially the result of our evolutionary past.
There is more, and recent, antiscience fare from far-left progressives, documented in the 2012 book Science Left Behind (PublicAffairs) by science journalists Alex B. Berezow and Hank Campbell, who note that “if it is true that conservatives have declared a war on science, then progressives have declared Armageddon.” On energy issues, for example, the authors contend that progressive liberals tend to be antinuclear because of the waste-disposal problem, anti–fossil fuels because of global warming, antihydroelectric because dams disrupt river ecosystems, and anti–wind power because of avian fatalities. The underlying current is “everything natural is good” and “everything unnatural is bad.”
Whereas conservatives obsess over the purity and sanctity of sex, the left's sacred values seem fixated on the environment, leading to an almost religious fervor over the purity and sanctity of air, water and especially food.
I'm worried that Shermer has confused liberal Luddism with denialism, and I would argue some anti-technology skepticism is healthy and warranted. While I agree that the anti-GMO movement does delve into denialist waters with regularity, these are not good examples he has chosen. One needs to be cautious with technology, and it's a faith-based assumption that technology can solve all ills. I'm with Evgeny Morozov on this one, the assumption there is (or should be) a technological fix for every problem has become almost a religious belief system. Appropriately including the potential perils of a technology in its cost-benefit analysis is not a sign of being anti-science. Even overblowing specific risks because of individual values isn't really anti-science either. It might be anti-human to put birds before human needs as with wind turbines, but no one is denying that wind turbines generate electricity. And while liberals may be overestimating the risk of say, nuclear waste generation over carbon waste generation (guess which is a planet-wide problem!), it doesn't mean they don't think nuclear power works or is real. They just have an arguably-skewed risk perception, which is an established problem in cases of ideological conflict with science or technology. There is also reasonable debate to be had over the business-practices of corporations (Monsanto in his example), which need and deserve strong citizen push-back and regulation to prevent anti-competitive or abusive behavior.
Anti-science requires the specific rejection of data, the scientific method, or strongly-supported scientific theory due to an ideological conflict, not because one possesses superior data or new information. I don't think Shermer actually listed very good examples of this among liberals. If you're going to talk about GMO denialism, don't complain about people fighting with Monsanto, talk about how anti-GMO advocates make up crazy claims about the foods (see natural news for example) such as that they cause autism, or cancer. And even then it's difficult to truly say this is a completely liberal form of denialism as Kahan's work shows again, there is a pretty split ideological divide on GMO.
I agree that liberals are susceptible to anti-science and the mechanism is the same - ideological conflict with scientific results. However, the liberal tendency towards skepticism of technology is healthy in moderation, and anti-corporatism is not automatically anti-science. In an essay that was striving to say we must be less ideological and more pragmatic, Shermer has wrongly lumped in technological skepticism, and anti-corporatism with science denial.
In studies done between home birth and hospital birth in the Netherlands it was found that comparing the numbers as is done above is misleading. The 40k hospital births will more or less consist of fair representation of society. Not so for the 2k home birthers. These tend to be either people whom for some reason cannot afford hospitals, who home birth out of some conviction (religious or natural) or who tend to be older couples who want to have the comfort of home during birth for the second child. In all these cases the chance of higher child mortality is a given, independent of home or hospital.
Umm, no. The situations are not comparable, and the Netherlands data do not support the safety of midewifery like advocates would like.
In the US, the increase in homebirth is largely from white women, usually multiparous and older. Further, they are selected for low risk births, singletons, and generally in patients with lower risk profile opt for planned home birth. Everything should bias them towards having a lower risk profile than that of hospital birth, and one can't blame this on poverty or rural inaccessibility (even more so in Oregon). CDC statistics over 20 years of births show these births are most common to multiparous, white (81%) women.
In the Netherlands the majority of low-risk pregnancies are attended by midwives (it should be noted they also have the highest perinatal mortality in Europe), with comparable mortality in and out of the hospital. However, the high-risk birth in hospital attended by OBs have a lower mortality that the low risk births attended in hospital by midwives. Worse, the data showing equivalence do so by subtracting out all the situations that occurred out of hospital that contribute to neonatal mortality (congenital anomalies, premature births, intrauterine growth retardation and low Apgar scores), which basically makes the study meaningless. It says, when nothing goes wrong out of the hospital it's about as safe as when nothing goes wrong in the hospital. You don't deliver in the hospital with the expectation nothing will go wrong, you deliver in the hospital knowing childbirth is serious and things can and do go wrong.
You also need to know that in the US, we have the CPM or "Direct entry midwife" certification that has minimal requirements before being allowed to attend births. They only just increased its stringency to require a high school diploma. US DEM practitioners can not be compared to the well-trained midwives in the Netherlands. It's not surprising to see, then, that the DEMs have the worse rate of neonatal mortality based on the Oregon data.
There is no support here for a demographic bias against midwifery, if anything it's the exact opposite.
For me the main point that Shermer misses is that yes, there are individual liberals that may hold un-scientific ideas, but these ideas are not actively pursued and legislated at the highest levels of government by "liberal" politicians ( not that there really are any of those at the highest levels of government). Shermer is engaging in ludicrous false equivalency.
Rebecca Watson fisked the Shermer article back in January:
With regards to the anti-GMO activists, I do think that anti science and denialism is a good description for at least some of their arguments. A large component of the anti-GMO argument is that there is something inherently different about crops derived from GMO techniques as opposed to standard breeding techniques, even when the actual change to the plant itself is negligible. It's not just that they misrepresent evidence, but that they promote and perpetuate misunderstandings about DNA, reproduction, and evolution.
They also use the tried and true creationist tactics of moving the goalposts. I know people who refuse to believe that any GMO crop is safe until there is a 20 year human feeding study. Never mind the logistical and ethical problems involved, in fact these people claim that if such studies cannot be done, then the crops shouldn't be used. It is denialism, absolutely. There is a difference between someone who says "I am suspicious about food developed with new technology, I would like to see some good safety data" and someone who, upon seeing good safety data, refuses to accept it and demands studies that are impossible to conduct and are far beyond what would be required for hybrid crops, all because of concerns that are scientifically implausible.
And this does have a very real effect when you get groups like Greenpeace urging African leaders to refuse food aid that contains GMOs (which would be most American crops) during famines, or preventing the use of Golden Rice to alleviate vitamin A deficiency in the developing world.
However, as Kerry points out, one major difference is that the Republican Party often panders to their anti science crowd, and even bases policy proposals on those ideas. By contrast, the Democratic Party has been very good about telling the HuffPo crowd to go sit at the childrens' table and not interrupt the adults while they're talking. I do think that this is an important distinction, as I would absolutely be willing to hold my nose and vote Republican if I felt that the Democratic Party was embracing anti-science messages. I think it's important to encourage the Democrats to continue to demand scientific evidence for any policy proposals and I think it would be a good thing to encourage the Republicans to do the same.
I'm afraid all the homebirth stats prove to me yet again is that it is the practitioner who makes birth safe. If you sideline midwifery, make it low status and deny access to good quality training and supervision, mistakes will be made. Countries where midwifery care is central, like the UK, have comparable, on my many levels, better, homebirth stats. Please don't extrapolate the US situation or use it to tell us anything interesting at all about homebirth...and please...not Ms Tuteur! She is the most unscientific person I've ever had the displeasure to bump into on the internet! Her cause has become a religion to her - any any evidence based, rational thought has therefore deserted her.
It is definatly not a trend I would support at all. Although it is sort of in keeping with the "freedom of choice" crowd in the anti-vaccine movement. (I think both definatly were liberal brain children at the start but libertarians love the same things now). Either way, the ideology of the problem matters insomuch as how widespread the thought process is dissiminated. Hopefully, these numbers can be reversed but who knows?
Some people really just do not trust the system and want to be more natural. Not sure how that should be addressed either.
Unfortunately your source for the graphic and information on homebirth infant mortality rates is incorrect. And while Dr. Amy did use the graphic in her blog, it does not come from her, the actual source of this data comes from Judith Rooks: "a certified nurse-midwife, a past-president of the American College of Nurse-Midwives, and a CDC-trained epidemiologist who has published three major studies of out-of-hospital births in this country (US)" You can find the original PDF document here, I suggest you update your information: https://olis.leg.state.or.us/liz/2013R1/Downloads/CommitteeMeetingDocum…
a man wrote this. How can i tell.. yeah read it again. This is a personal choice. They are both safe, Hospitals are dirty , doctors and nurses impersonal. midwifes have passion and love , been doing this since woman have been giving birth,,, mmm think ill take the more natural way ... western medicine, doctors , big pharma .. corrupt money hungry whores ... just sayin .
I’m afraid all the homebirth stats prove to me yet again is that it is the practitioner who makes birth safe. If you sideline midwifery, make it low status and deny access to good quality training and supervision, mistakes will be made.
I would agree, practitioner makes a big difference and OBs are the best practitioners. And who is denying access to RN training? This data demonstrates that even nurse midwives delivering out of hospital have a mortality rate about 7 times higher than in hospital. So here I would argue it's not just a matter of training, it's about ready access to resuscitation, and diagnostic and surgical technology.
Countries where midwifery care is central, like the UK, have comparable, on my many levels, better, homebirth stats.
The Netherlands data would suggest otherwise. However, it's true, when you train people for birth, they will be better at dealing with it and it's potential complications. I'm all for more training. But that's not what's going on here. We have a clear and obvious problem, and the data reflects this. Any conversation about birth location in this country should start with a discussion of risk to the infant, and data such as these demonstrate significant increase in risk to the infant for the sake of a better birth experience.
Please don’t extrapolate the US situation or use it to tell us anything interesting at all about homebirth…
I wasn't aware that I had. But how about we take a look at some British data? Here is the largest study I could find on British homebirth. I wouldn't say that I'd agree that homebirth is equivalent to obstetric supervised birth there either. Based on their primary outcomes:
Primary outcome was perinatal mortality and intrapartum related neonatal morbidities (stillbirth after start of care in labour, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, fractured humerus or clavicle).
the obstetric rate of events for nulliparous women was significantly higher as obstetric rates were 5.3 per 1000, while home births came in at 9.3 per 1000.
Worse, if you start digging into the supplementary data you see the odds ratio for one of these primary outcome measures for a nulliparous woman at home vs obstetrical unit is 4.6, and 1.9 for all women when you eliminate centers with a low response (decreasing the likelihood of fudging by under-reporting). Uh oh.
I'd say that's better than what we're seeing in our country, but still not perfect. I'd say reasonable advice for homebirth in UK should still include obstetrical unit for first birth, as you may greatly reduce the risk of one of these outcomes.
and please…not Ms Tuteur! She is the most unscientific person I’ve ever had the displeasure to bump into on the internet! Her cause has become a religion to her – any any evidence based, rational thought has therefore deserted her.
She is Dr. Tuteur, by the way, and to date I haven't seen any evidence of unscientific behavior on her part. The midwives, however, slander her, file false DMCA takedown notices on her site, and refuse to release data. One side of this debate is using the literature and data for argument, the other is using what exactly? I'll stick with Tuteur until you show me some actual evidence of unscientific behavior other than "saying things I don't like to hear".
On energy issues, for example, the authors contend that progressive liberals tend to be antinuclear because of the waste-disposal problem, anti–fossil fuels because of global warming, antihydroelectric because dams disrupt river ecosystems, and anti–wind power because of avian fatalities. The underlying current is “everything natural is good” and “everything unnatural is bad.”
Sadly, I have to agree with this assessment, in many cases. Part of the problem being the "assumptions" made. Nuclear - there are "small scale" type designs, where the fuel problem isn't as bad, or the transportation as costly, like say, pebble reactors. They are just not seen as being "cost effective", because you need a lot of them, not just one big one.
The dams... actually are a problem, in many cases, and its not just fish they effect, but, again, some of this is "scale". I suspect there could be ways to provide "local" power instead of "wide scale", which requires a huge dam to produce.
The wind power thing, however, is just pure idiocy. The bigger your blades, the slower the system not only does, but "must" turn, and the problem with existing wind farms is that their design are smaller, and therefor turn so fast that birds can't see them, so run into them.
Most of the anti-science on the left comes from misinformation and a lack of the willingness to check their own facts. The right... tends to reject things on ideology, rejecting not just the idea that they should check their facts, but the facts themselves, when presented, and their reason for not believing something is not "worry about the real dangers", but, all too often, imaginary ones, or worse, a lack of worry, because the same imaginary source of information tells them, "This can't happen, so drill baby drill."
But, yeah, there is a "bit" of that going on on the left, at least as relates to things like so called "natural birth", but such people are "left" only because they right hates everything they stand for. They are certainly not there because they are better informed, have a scientific perspective, etc. And, because of that, you are bound to find that, despite claims to the contrary, there is a wide overlap between their particular delusions and those on the right, who hold similar opinions, even if its only one those "specific" same subjects. Its crank magnetism. Completely apposed political stances are not sufficient to prevent homeopaths, or home birth advocates, or other such people from banding together one moment, when defending a stupid idea, and calling each other fools the next.
We don't know why there is a small but statistically significant difference in adverse events for primips in the UK Birthplace study and I agree it warrants more study. Women deserve to know the facts before making decisions about where they give birth. But it doesn't surprise me that women get vso angry when they read things like this blog - you use our study of 65,000 births to prove a point - that out of hospital birth is more dangerous, when actually the study proved that births in birth centres for all women and homebirth for multips was AS SAFE as hospital birth.
But this stuff doesn't interest me as much as the fact that, whatever the stats, and whatever social engineering you do to encourage hospital birth, women for all sorts of very valid reasons will choose to birth at home. This being the case, we have a social responsibility to make sure they are as safe as humanly possible. I assume that you wouldn't condone them being left to birth unattended, or to be frogmarched into hospital by the maternity police?
"OBs are the best practitioners". Midwives catch almost ALL the babies here in the UK and OBs only help with difficult cases. Our overall stats in all catagories leave the Yanks standing...in fact it's safer to give birth in 40 other countries than the US. I suggest you ask yourself why.
Just for the record, I'm not a 'homebirth advocate' whatever that is. But I am a feminist who's had enough of people telling me where, when and with whom I play out a bodily function. My body, my baby, my choice.
Thanks for the comment Mark. I dont know enough to claim midwifery / homebirth is safer or more dangerous than OBs / hospitals.
All I claim is that without a comparison of population differences any study done is practically meaningless.
The study you quote puts it like this:"
The authors compare their results with other homebirth studies, noting that home and hospital populations differ markedly in risk profile and that any study of homebirth outcomes must correct for these differences."
The second study is worse: "
An important limitation of the study is that aggregated data of a large birth registry database were used and adjustment for confounders and clustering was not possible. "
Meaning that you cannot conclude anything from this data (same as from many studies before this one). Maybe I missed it but I dont see a comparable study done by Dr Tuteur either.
Until an apples to apples study is done over large enough population incorporating the varies factors this will be a debate where both sides are equally right.
And yet again we have another man telling women what they can and can't do with their bodies - it is a woman's right to decide. And the European Court of Human Rights agrees - see their judgment in the case Ternovzsky v Hungary - http://hudoc.echr.coe.int/sites/eng/pages/search.aspx?i=001-102254
By quoting that woman as a credible source you lost all credibility.
I love the reading comprehension michelle. From above:
Armed with data such as these, it needs to become a point of discussion for both obstetricians and midwives that out of hospital births have a dramatically-higher neonatal mortality, and this is worse for midwives without nursing training (the DEM or direct-entry-midwives). It’s their body and their decision, but this information should be crucial to informing women as to whether or not they should take this risk.
Nice try guys. But I'm not telling women what to do with their bodies. If you want to increase the chance of higher morbidity and mortality in your child for a better birth experience that's your choice, I am advocating for it to be an informed one.
As far as the UK direct-entry midwives, looking at their certification, it's a significant process. Based on the wiki if believable, we're talking about 3-5 years of training at universities, with registration and certification that's rigorous. Here in the US it's clearly a less stringent process, and advocates vehemently fight against any additional rigor. To become a CPM you have to take a little test and attend a handful of births. Birth is serious business, and the training for those who attend birth needs to be equally serious. OBs, given their enormous breadth of experience and capacity for surgical action in the face of disaster are clearly the most qualified. While it may not be necessary or possible to have that level of training at bedside at every birth (although I think in the US it is), I think these data in Oregon show a definite benefit of proximity to the experts. The difference seems to have resulted in an extra dozen or so dead infants in 2012.
@Robert 13, the thing with all these studies is that even biasing towards an easier patient population for the midwives (no on thinks they should be delivering high-risk, breech, twins, previa etc), they still have poorer mortality. The OBs, even given the higher risk births, and in the US the transfers from out-of-hospital births gone bad, still have lower mortality rates. The reasons are obvious to me, I've seen them at work, make a decision for surgery in seconds, and have a baby in distress out and breathing in a matter of minutes. Maybe they do too many procedures as a result, but the benefit is clear - more living babies.
You are assuming that the studies bias towards an easier patient for the home birthers and midwife birthers. My point is that no study actually proves that. In earlier studies in the Netherlands it was shown that home birthers are for instance on average 10 years older then hospital birthers. That makes child mortality go up no matter what. Background, ethnicity, etc all can influence the rates as much as having a less risk patient or a better deliverer.
You are probably right that OBs and hospitals are the safer bet. Without actually proving that in a study though, its just talk.
No Robert, Multiparous women are generally less problematic, mortality from congenital abnormalities is being subtracted (so older less of an issue), and this is a predominantly white (80%) population who are electing for homebirth (see the CDC link above). All are factors which are going to bias towards better statistics for homebirth. Additionally, as a matter of course these are low risk pregnancies as even among midwives it's accepted their practice is primarily for low-risk pregnancies. Higher risk pregnancies are delivered in the hospital. Hospitals, even delivering high and moderate risk pregnancies as well as bearing the stats for the transfers from homebirths gone bad, are demonstrating lower infant mortality. Further, just being older doesn't necessarily increase risk, the largest study comparing age versus mortality in 260k women shows older is actually better with the ideal age between 26 and 30. The rate is actually a U-shaped curve, with mortality increasing sharply again after about age 35. Even if 100% of women in homebirth were > 35 years old, this would increase risk by only about 50%, where is the other 650% coming from?
When these are controlled for, as in the BMJ study, or when they are compared to all comers as in the Netherlands or CDC data, the OBs do better. It's not just talk. It's the data.