MBP Again! A Scientific Perspective?

Well, just as I was preparing my next topic for discussion, MBP has resurfaced as the big subject of conversation in the rationalist blogosphere.  So I just HAD to say something, so here it is.  First, please read this article here.  A well known group of MBP defenders authored this article, and it is important to read before you continue with this post.  Second, please read R Natan Slifkin's response to this article here.  Now you are prepared for what I have to say.

The article is full of very tricky language and misleading use of medical literature, so one has to be careful not to fall into the trap being laid out by the authors.

They begin with a statement designed to make one think that New York City is outlawing a religious practice:

"In  September 2012, New York City passed a regulation declaring metzitza be peh (MBP), a part of many ritual circumcisions, illegal, unless the circumciser or mohel obtains a signed form from the parents, including: “I understand that direct oral suction will be performed... and that [the New York City Department of Health and Mental Hygiene] advises parents that direct oral suction should not be performed because it exposes an infant to the risk of... herpes (HSV)... infection, which may result in brain damage or death.”

The language chosen by the authors, that MBP is "illegal", is a deliberate misrepresentation of the actual regulation.  The NYC government website here describes the regulation in a very clear manner.  It is clear that the city deliberately avoided making the practice illegal, and simply required a consent form prior to its performance.  While one can argue that this is simply an argument over semantics, sometimes a choice of language can be highly misleading even if it is technically true.  Especially when the pattern repeats itself throughout the article as I am about to demonstrate.

Why would they choose to misrepresent the true nature of the city regulation?  Of course they do so in order to frame the city health department as the enemy of religion, instead of simply as acting in their proper capacity in their mandate to protect the health of the citizens of New York City.

I will take a pass on the legal comments that follow in the next two paragraphs of the article, simply because I am not a legal scholar and don't know enough to comment on the nuances of the court decisions.  However, they then continue as follows:

"In response to the ruling, Sam Sokol wrote, on these pages, an article entitled: “Analysis: New York circumcision controversy emblematic of longtime Orthodox ideological split,” advancing two positions: (a) “Contemporary medical knowledge” supports the assertion of a causal link between MBP and HSV infections, as stated by the Centers for Disease Control and Prevention and “several prominent contemporary decisors of Jewish law (poskim)” – specifically Rabbi Tendler, described as a son-in-law of Rabbi Feinstein, and Rabbi Slifkin, otherwise known as the Zoo Rabbi; (b) MBP is practiced by a fringe segment of the ultra-Orthodox."

In item "a", the authors claim that Rabbi's Tendler and Slifkin are the rabbinic advocates of the idea that there is a causal link between MBP and HSV infections.  This is both highly confusing and grossly inaccurate, as neither of these Rabbis ever claimed to be the source of the assertion that there is a causal link between MBP and HSV.  The causal link was reported in the medical literature, and each Rabbi reacted to the information appropriately: Rabbi Tendler, in his role as a posek, by proposing that other forms of metzitzah are halachically acceptable; and Rabbi Slifkin, in his role as a popular proponent of the Rationalistic approach to Jewish tradition, by explaining how different streams of Judaism would react to this scientific information.  Neither Rabbi ever "advanced" the "position" that MBP causes HSV, as the authors claimed.

The authors also identify these two rabbis (WADR to these two individuals), as if they are the only rabbis who have supported halakhic alternatives to MBP! When Sokol wrote about "several prominent decisors of Jewish law" he was referring to none other than the Chasam Sofer, Rav SR Hirsch, Rav Azriel Hildesheimer, and numerous other poskim throughout the generations!

But then in item "b" they fall right back into their pattern of using misleading and deliberately incendiary language.  They claim that Sokol "advanced the position" that "MBP is practiced by a fringe segment of the ultra-Orthodox".  Once again they choose language that portrays their detractors as the enemy, as if Sokol was demeaning the practitioners of MBP by calling them a "fringe segment."  In fact, Sokol uses no such demeaning language, as he tried in his article to be balanced and open to the fact that there are different streams and approaches to this issue.  They are trying to pick a fight, while Sokol was simply being open and honest.

However, the real problems begin when they start quoting the medical evidence. 

Allow me to explain some basic facts that most people who are not familiar with reading medical articles are not necessarily aware of.

First fact. To prove a true causal link between two variables "a" and "b" is extremely rare and extremely difficult in modern medicine.  Even when data strongly suggest an association between the two variables, one can often claim that a hasn't actually been proven to cause b.  See this article in Wikipedia which explains this concept.  Therefore, the authors are actually correct when they claim that no causal link has ever been proven.

However, if a correlation between MBP and HSV infections in the newborn has been identified (which has been identified), and there is a clear mechanism by which MBP can cause HSV (which there is), and this implied causation fits with everything else we know about both variables (which it does) then assuming a causation between a and b is extremely reasonable even if technically one can claim that it hasn't been "proven".  Especially when the danger and risk of assuming that no causation exists is so significant. So the authors are playing the semantics game again by claiming that there is no "causal link".  While it is a true statement, it is also a very dangerous statement.

Another fact.  Every single study published in scholarly medical journals ends with a section describing the limitations and flaws of the study.  This is important for any honest researcher to recognize openly the particular shortcomings of their work.  Even the most widely accepted and influential studies have flaws, and it is  always important for physicians who use these studies to care for their patients to understand the limitations of the evidence presented. However, recognizing the limitations does not invalidate the findings of the study, it simply helps us understand the limits of the practical application of its findings.

So now let's look at the following paragraphs:

"A 2013 University of Pennsylvania study, moreover, analyzed the relevant evidence and all the prevailing literature and concluded that: “This evidence base is significantly limited by a very small number of reported infections, most of which were not identified or documented systematically. Other important limitations include incomplete data about relevant elements of the cases, the presence of confounding factors, and indirect data sources.”

"As to the single study claiming statistical evidence for an elevated risk among babies who underwent MBP, the Penn report noted that the study lacked scientific foundation: “this finding is limited by methodological challenges in determining the total population at risk, limited information about some of the cases, and the small number of infected infants.”

These paragraphs are so grossly misleading that it is obscene. The actual conclusion of this Pennsylvania study reads as follows:

"...Standard principles of infectious disease suggest that exposing a neonatal circumcision wound to human saliva, even briefly, creates a risk of HSV transmission... Neonatal HSV infection can cause severe morbidity and death, so mitigating potential risks for infection is critical. Current evidence suggests that direct orogenital suction during ritual circumcision was the likely source of infection in recent cases that resulted in significant illness and death (emphasis added)..."

The authors simply ignored the findings and conclusions of the entire University of Pennsylvania article, and they blatantly contradict the opinions and assertions of the researchers.  Instead they chose to quote those few sentences in which the researchers honestly discuss the understandable limitations of their study.  In fact, the Pennsylvania researchers recommended that the only way to prove causality would be to design a randomized trial with two groups of ultra orthodox Jews, in two cohorts, and to perform a proper prospective trial.  We all know that this would be completely impossible to do, as the ultra-Orthodox would never cooperate with a trial that asks half of them to randomly decline MBP.

We therefore have to rely upon the best science available, and on common sense.

Although this concludes my analysis of what was written in the article,  I cannot leave the topic without mentioning what was not written in the article. No mention of the following scientific articles that support the relationship between MBP and HSV infection:

Gesundheit B - Neonatal genital herpes simplex virus type 1 infection after Jewish ritual circumcision: modern medicine and religious tradition. Pediatrics - 01-AUG-2004; 114(2): e259-63

Centers for Disease Control and Prevention (CDC) - Neonatal herpes simplex virus infection following Jewish ritual circumcisions that included direct orogenital suction - New York City, 2000-2011 MMWR Morb Mortal Wkly Rep - 8-JUN-2012; 61(22): 405-9

Distel R, Hofer V, Bogger-Goren S, Shalit I, Garty BZ. Primary genital herpes simplex infection associated with Jewish ritual circumcision. Isr Med Assoc J 2003;5:893–4

Rubin L, Lanzkowsky P. Cutaneous neonatal herpes simplex infection associated with ritual circumcision. Pediatr Infect Dis 2000;19:266–8

Koren A - Neonatal herpes simplex virus infections in Israel Pediatr Infect Dis J - 01-FEB-2013; 32(2): 120-3

Yossepowitch O1, Gottesman T, Schwartz O, Stein M, Serour F, Dan M. Penile herpes simplex virus type 1 infection presenting two and a half years after Jewish ritual circumcision of an infant.  Sex Transm Dis. 2013 Jun;40(6):516-7

These are just some of the articles that have been published and have been ignored by the authors.

In summary, the authors of this article chose to:

1. .... mischaracterize the New York City government as if they were somehow trying to outlaw a religious practice, while in fact the City was only trying to protect the health of its' citizens, while preserving their religious rights
2. .... misrepresent Rabbis Slifkin and Tendler as if they were the ones who asserted that there was a causal link between MBP and HSV, while they simply were using the available medical information to discuss areas that they are fully competent and qualified to discuss.
3. .... identify the above two rabbis as if they are the only Orthodox Rabbis who support alternatives to MBP, while numerous rabbis including the Chassam Sofer are the actual sources for the halakhic alternatives!
4. .... misquote Sam Sokol by claiming that he referred to "fringe segments" in order to make him sound like he was demeaning to the practitioners of MBP
5. .... state that no "causal link" has been identified between MBP and HSV, which although in the strictest sense it may be true, it completely misrepresents what contemporary medical science believes to be true based on the overwhelming available evidence
6. .... completely and utterly ignore the findings and conclusions of the most important and most complete study of the relationship between MBP and HSV, and instead to quote the researchers discussion of the limitations of their study
7. .... completely and utterly ignore the scientific studies that contradict their contention that MBP does not cause HSV

 

Organ Donation after Cardiac death

Just a quick post before Shabbat begins.  I noticed an article in the Jerusalem Post that may have an effect on the way the Chareidi community views becoming an organ donor. Apparently, doctors in Israel were successful in transplanting a kidney from a donor that had been without a heartbeat for several hours.

This is an exceptional accomplishment, because it opens the possibility for those who believe in Cardiac death to donate their organs after what they consider to be halachic death.  (See my extensive posts from October 2010 for more on this topic). Whether or not it actually changes the practice of the Chareidi world remains to be seen of course.

Just FYI, there still is a long way to go before it can become regular practice to harvest donor organs after cardiac death.  The new techniques will need to be tested and attempted on other organs as well as the kidneys.  Furthermore,  harvesting the organ prior to cardiac death is still much more likely to be successful.  However, maybe it can open the path for a Chareidi living will that explicitly states that the individual is willing to donate his/her organs if cardiac death is established first.

This may turn out to be a real opportunity for the Chareidi world, once organs can be donated even after cardiac death, they can join the ranks of the potential organ donors! I certainly hope we see that happen!

MBP - Does a rinse with Schnapps help?

I must admit that I was somewhat caught by surprise by the overwhelming responses to my previous post about MBP.  In addition to the comments that are published, I received many emails as well, and tried my best to respond to all of them. Sitting up late at night in the hospital can sometimes be a useful time for emails!  I used to use that time for Nach Yomi, and catching up on medical articles, but now it seems to be email and blog time! BTW, Nach Yomi is an OU program that has changed my life, and I highly recommend it to the many Nach deficient people out there.  If even one of you takes up Nach Yomi as a result of my encouragement, then this blog may turn out to be something useful after all! But let's get back to MBP.

If at all possible, I beg you to comment publicly on the blog rather than send me an email.  I want everyone to benefit from your thoughts, whether you agree with me, or not.  If you want to remain anonymous, I have no problem with that at all.  The discussions generated by the comments can be very interesting and beneficial for everyone, and it allows me to respond publicly.  I will still read and respond to emails, but please let everyone benefit from your ideas, not just me.

One of the issues that has come up over and over again is the question of whether or not rinsing the mouth with wine or whiskey helps mitigate the risk of transmission of the HSV virus.  One person even wrote to me in an email, that apparently in Yemen, the custom was to perform the MBP with a mouthful of Arak, and even to rinse several times.  His source was Rav Kapach's Sefer Halichot Teiman.  Since there has been so much interest in this topic, I am dedicating this post to the question of alcohol rinses and HSV transmission.

There are many reasons why the alcohol rinse does not mitigate the concern for HSV transmission.  For starters, alcohol as a disinfectant loses most of its potency when it is less than 60-90% concentration.  Even the strongest whiskey's are rarely more than 40-45% alcohol.  See the CDC here for details on the concentration of alcohol necessary for it to have any useful potency for germicidal use. Furthermore, bear in mind, that the alcohol is further diluted as soon as it is placed in the mouth by natural saliva.  So the alcohol used is simply not strong enough to kill bacteria or viruses.

In addition, even if one were to use pure ethyl alcohol to rinse the mouth, it would still be impossible to kill all the viruses and bacteria present in the mouth.  The mouth is full of areas to which the alcohol will never reach, such as the gums, between the teeth, all the folds between the cheeks and lips and the teeth and so on. It is well known that it is impossible to actually disinfect the mouth.  So even if you could reduce the amount of virus present in the mouth, there is no way anyone can eliminate the possibility of transmission.  To make matters worse, the skin on the outside of the lips can transmit virus as well, and this area is never rinsed.

We also need to bear in mind, that the germicidal activity of alcohol, even when it is potent enough to kill bacteria, is measured when it is used on smooth surfaces, together with scrubbing the surface.  In order to effectively replicate this, one would have to scrub every surface within and around the mouth (which is absolutely impossible like I described before) with alcohol with at least a 70% concentration!

The bottom line is that the alcohol  in wine and schnapps is simply too weak to be effective, and even if it were an adequately strong germicide, the mouth cannot be disinfected.

I think it is worthwhile to bring another example that will hopefully drive home the point that the only way to eliminate the risk of HSV transmission is to eliminate the direct contact between the one who has the virus and the baby.

We all know that surgeons sterilize their hands and arms, or "scrub", before performing surgery and coming into contact with open wounds.  However, would anyone ever even think of allowing surgeons to operate bare-handed just because they washed their hands really well and scrubbed them with germicidal solutions?  Of course not! We mandate gloves and gowns and etc. because it is common sense to eliminate contact between the surface of the surgeon's hands and the open wounds.  That is the only way to guarantee that germs do not get passed back and forth.

In the same way it makes no sense to allow contact between someone's open mouth and the open circumcision wound, no matter how much schnapps one may rinse his mouth with.

MBP - Dispelling Some Common Misconceptions

The mere sight of the term MBP (Metzitza B'Peh - direct oral/genital suction of the circumcision wound) may set off fireworks in the minds of many of the medical halachic rationalist readers of this blog.  Some of you might have been waiting for me to say something about this subject. MBP has been in the news lately due to some high profile court rulings in New York, so it is once again a hot topic.  However, I must disappoint you by admitting that I don't have that much to add that hasn't already been said.  In fact, a close friend of mine, Shlomo Sprecher, has already written what I consider to be the most definitive rationalist medical halachic (even if he didn't use the term "RMH" to describe it!) article on this topic, and you can read it here.  I highly recommend that you read it if you haven't already done so.

However, I have come across an extreme amount of ignorance when it comes to understanding exactly what the medical concerns are regarding the transmission of HSV (Herpes simplex virus) and circumcisions.  The ignorance in the Orthodox Jewish world seems to reflect the ignorance of the general population about this virus, which I encounter on a regular basis in my medical practice. As such I feel like I need to counsel everyone regarding how this virus works, and then you can understand what the issues really are.

For starters, HSV is a virus.  That means that it cannot be treated with antibiotics.  This particular virus has the nasty habit of being incurable, which means that once you become exposed to it, it will be in your system forever.  It has figured out a way to hide deep inside your nerve roots ("ganglia") and hang out there for the rest of your life.  Every once in a while it may decide to leave its hiding place, travel up the nerves to your skin, and cause a lesion to pop out on your skin and annoy you.

When this happens, the sore is likely to shed more virus, so if someone else becomes exposed to it, he/she can catch it from you.  However, the virus is even sneakier than that.  Sometimes it travels out to your skin and sheds virus, but doesn't show any sores at all.  This is called asymptomatic shedding.  This means that you can be shedding and transmitting the virus and have no idea at all that it is going on. While an active lesion is much more likely to shed virus than when there are no symptoms, it is well known that asymptomatic shedding can and does occur.

So that's the bad news, what is the good news?  The most important good news is that HSV is generally not a very dangerous virus at all, in the overwhelming majority of cases.  The vast majority of people with this virus will go about their innocent lives and have virtually no consequences, except maybe an annoying sore every once in a while.  Most people don't even know that those annoying sores are HSV, they just think it is a pimple that came and went after a few days.  They usually don't even know that they have HSV, and they certainly don't know that they can transmit it to someone else!

But that good news can also be bad news. Why is that? Because if you don't know that you can transmit it, and it can be transmitted even if you have no symptoms at all, how are you supposed to prevent the transmission of HSV throughout the general population? Well, guess what! You now understand why close to 90% of the adult population of the US has been exposed to HSV 1 at some point in their lives.

When two moist surfaces of the body, such as the oral region, and/or the genital region come into contact, and one surface is shedding HSV, this is the most effective way to transmit the virus.  If one person has a cold sore (which is caused by HSV), or is shedding asymptomatically, and people share a cup, a kiss, share a food utensil, wipe their mouth or cough and then pass the kugel, or any other moist contact, the virus can be transmitted.  Of course the chances are very small each time this type of contact occurs, but if it happens over and over again, it only takes once ...

The vast majority of people will have been exposed to HSV in this manner.  By now you should understand that a person with HSV 1 is usually not infected because he/she is guilty of some type of sexual contact. Most of the time it was completely innocent, and most of the time the person him/herself is never even aware of having been exposed.

You probably noticed that I mentioned HSV 1, which means that there is another type called HSV 2.  This is a very closely related virus that tends to hang out more in the genital region.  This type is usually transmitted through genital or oral/genital contact.  However, there is much crossover between the two types, as HSV 1 is often found in the genitals, and HSV 2 is often found orally as well.

HSV 1 outbreaks are generally more mild than HSV 2 outbreaks, and especially with HSV 2 in the genitalia, the first outbreak can be quite severe.  But both types of the HSV virus have a very similar clinical course, and they are transmitted in basically the same way.  The reported cases of HSV transmission through MBP in New York were HSV 1 cases, not HSV 2. This is important because HSV 1 is much more common, and is still more associated with Oral infection than with genital infection.

So what's the big deal? If it is true that HSV is only a nuisance and rarely causes health problems, why is it such a concern? What is all the hoopla regarding MBP?

The big deal is that in certain very rare cases, if HSV gets into certain body fluids it can cause very serious problems.  Those two places are the blood, where it can cause viremia (a viral blood infection) or in the brain where it can cause encephalitis or meningitis.  Viral infections such as these can be extremely dangerous, and are notoriously difficult to treat, especially because antibiotics do not work against viruses.  Furthermore, as you recall, there are no cures for HSV.

When would someone be at highest risk for such a horrible infection of the blood or the brain with this virus?  For starters, if it is introduced directly into the blood. That would be really bad.  Now if you take a person who does not have a very strong and mature immune system, that would be worse.  Then if it enters the brain of someone who is still developing neurologically, that would be tragic beyond words.

Now let's make it scarier.  Let us find a well meaning person.  This person seems perfectly healthy.  He himself has no idea that he has any infections of any type. Everyone around him knows that he is "very clean" and scrubs his hands really well.  He has lived a virtuous lifestyle and has never exposed himself to any situation which would make one concerned that he may have gotten any transmittable diseases.  Maybe when he was a child in cheder he shared a cup of juice and got a little cold sore, which went away after a few days because his Mom shmeared on some Vaseline.  He was a little "tzaddik'l" and went on to become a popular Mohel.  But he has this HSV 1 virus for life.  In his mouth.

Let us go further. This mohel never sees any lesions that he thinks could represent a major health risk, except occasionally he may get a cold sore which he thinks is just chapped lips.  The mohel is such a tzaddik and so well loved and well respected that he does a Bris Milah just about every day in his community.  Asymptomatic shedding is very rare, so it only happens a few days a year, but he does a bris milah every day ....

And one fine day, a happy young couple brings their beautiful little child to shul for his bris milah.  The well meaning, wonderful Mohel performs the ceremony.  He does MBP. This young child, with an immature immune system, and a developing nervous system, now has an open wound, giving the virus direct access to his bloodstream, and to his newly forming brain.  The Mohel happens to be shedding virus that day, and has no symptoms whatsoever. And the virus gets into the baby's bloodstream, and it replicates, and may God save us, a horrible, totally preventable, unspeakable tragedy occurs.

This is the problem.  Like I said before, the cases reported in New York were HSV 1, simple Oral HSV that 90% of the adult population has.  The only way to prevent it from happening is by avoiding the exposure in the first place and protecting our children from tragedy.  May common sense prevail.

Postscript:

In this post, I have tried to dispel the following extremely prevalent and extremely dangerous notions (I have heard ALL of these in murmurings at shul kiddushes, Shabbos tables, during leyning - bein gavra l'gavra only of course etc...)

1. If the Mohel is a genuine tzaddik and ben Torah there is no risk of herpes transmission
2. the Modern Orthodox are just trying to find ways to show that the Chareidim have Herpes infested Mohelim and they are all hypocrites
3. If the Mohel has no history of disease and has no herpes sores there can't be a risk
4. This Mohel has done thousands of Bris Milah ceremonies and "no one" has ever had a problem (this would be extremely difficult to prove, and even if it was true, it still doesn't protect you)

If any of you have heard other such comments, I would be interested to hear them.

Home Births and Halacha

The authors conclude their article with a discussion of the issue of planned homebirth vs. hospital birth. In their words:

"Similarly it is commonly believed that the twentieth-century transfer of births from the home to the hospital has aided the cause of piqquaḥ nefesh by lowering infant mortality. Statistics, however, do not support such a belief. Western countries with more home births than in the United States have lower maternal mortality rates and lower infant mortality rates than ours.26 Australia, New Zealand, Japan, and all Western and Central European countries all have lower mortality rates than the U.S.’s, yet more than one-third of all of their births are planned home births attended by a midwife. ...

Within the United States, studies also show that for normal pregnancies, home births are at least as safe as hospital births and that births attended by midwives are safer than births attended by physicians. Certain procedures such as multiple vaginal examinations and routine premature rupture of membranes are commonly performed by obstetricians, but not by midwives. Rather than promoting piqquaḥ nefesh, these interventive procedures, which naturally necessitate viewing of and contact with female genitalia, have actually been shown to be dangerous to the birthing woman and to her child.  There is also growing concern—even among some obstetricians—that other interventions typical of doctors and not midwives, such as a high Cesarian section rate, diagnosis of “failure to progress” during labor, and prevalent use of drugs to hasten labor all have few health benefits and may indeed harm the baby."

The issue of planned homebirth has been the subject of significant discussion in recent decades, and there is no way that I can do it justice on this blog.  However, I will respond to the authors contentions with a few simple points that I believe are very important.  I will first refer the readers to the statement of ACOG on this topic here.  It is worthwhile reading, but as is often the case with medical literature, some important points still seem to be misunderstood by the public.

Before I explain anything, I need to remind the readers of this blog, that it is a blog for medical halacha and not meant to be a discussion of medicine.  So we need to establish the halachic issue here before we move on.  The halachic issue that the authors of the article are raising is that they contend that having a baby in a hospital may potentially be more risky then a home birth.  This would be a halachic problem, suggesting that a home birth may actually be safer and thus halachically preferable.  In their words, having a baby in a hospital exposes one to " ... interventive procedures ... [which] have actually been shown to be dangerous to the birthing woman and to her child..." Furthermore, according to the authors, " ... other interventions typical of doctors and not midwives, such as a high Cesarian section rate, diagnosis of “failure to progress” during labor, and prevalent use of drugs ... may indeed harm the baby."

Could it be that having a baby in a hospital is riskier than a home birth, and thus halachically prohibited?

The best and most comprehensive study evaluating this issue, is the one quoted in the ACOG statement that I linked to above.  This was a meta analysis evaluating all known scientific studies of home birth vs. hospital birth.  The bottom line is that even under the best of circumstances (and I will describe briefly those circumstances in just a moment) a home birth has a rate of neonatal death that is 2-3 times higher than hospital births.  Now it is extremely important to understand that the actual rates are so low, (1.5-2/1,000 vs. .4-.9/1,000) that the studies certainly confirm that a planned home birth can be considered safe if done properly.  But to claim that it is less dangerous than, and thus halachically preferable to a hospital birth is simply wrong.

Now here are the points that need to be understood.

1. No studies can actually be ever done that will truly answer the question of which birth is safer.  That is because in order to do this study, we would need to randomize women to planned hospital vs. planned home borth.  This is impossible in today's society.
2. In every study that did try to retrospectively compare (or prospectively without randomization)  the two birth locations; only women that were healthy, had uncomplicated pregnancies, and with normal and healthy babies were allowed as participants in the studies.  So the studies only established that in these types of cases (of course this represents the significant majority of pregnancies) that it is safe to have a home birth. No one disputes that this is true.
3. In all of the countries mentioned by the authors, those countries have in place highly integrated health care systems that address which women are candidates for home delivery, which personnel are certified and qualified to attend and supervise home deliveries, and transportation systems and communications for emergent transfer to a hospital are in place.

So we can all agree, that if proper systems and safeguards are in place; that a home birth can be a viable, safe, and halachically sound option for people who want to choose that type of delivery.  However, to suggest that a home birth is somehow halachically more preferable than a hospital birth is misleading and wrong.

In the United States, (I am not intimately familiar with the system in Israel) our health care system is set up to take care of women in labor in hospitals.  The poskim have thus overwhelmingly permitted (and encouraged) women to travel to the hospital, even on Shabbat, when they are in labor.  Whether or not it is preferable to have a baby at home (assuming that all of the conditions we mentioned above are in place), is a decision a woman needs to make with her qualified health care provider, and depends on many factors which are well beyond the scope of this blog.

I think that should conclude my discussion of this topic, but if you have any questions, comments, criticisms, etc... please let me know as I would love to hear what you have to say.

Obstetric Drugs

In the final section of the article the authors decry the use of drugs during labor to treat pain.

They refer us to the early debate regarding whether or not it is appropriate to use pain relieving medications to treat women in labor.  It is well known, that many early religious (mostly Christian, but some Jewish as well) authorities felt that pain was a natural part of labor, and that women were supposed to have pain due to the curse associated with Eve's sin when she took a bite of the forbidden fruit.  They felt that it was therefore inappropriate to provide women with pain relief.

This philosophy would strike most modern readers as incredibly cruel, and indeed the overwhelming response of the Rabbinic authorities has been to support, and even encourage, the use of anesthetic and analgesic medications to relieve the pain of childbirth.  The authors quoted R' Moshe Feinstein in YD:2 p140 where he recommended that women be put to sleep for delivery so as not to feel pain.  This responsa was written in 1972, when it was common practice to give women heavy doses of sedatives during the final stages of labor to treat pain.  This usually required the physician to intervene and deliver the baby with forceps as the woman was not awake enough to push the baby out herself.

This practice fell out of favor well over 35 years ago when doctors realized the risks of forceps deliveries when done routinely, and the risks of the medications involved in heavy sedation.  I am not aware of any doctors or institutions that have practiced this way in almost two full generations.

So the authors agree that Judaism does support pain relief during labor and does not subscribe to the "curse of Eve" philosophy which would prohibit pain relief.  However, they then introduce us to another concern, which they feel should be a halachic basis for avoiding the use of drugs during childbirth:

"... Nevertheless, not all objections to obstetric analgesia and anesthesia can be dismissed as mistaken religious obscurantism based on the Genesis narrative.

As Rabbi Immanuel Jakobovits outlines, Christian objection to the use of drugs during childbirth was two-pronged. While some cited the curse of Eve as their source, others objected for medical reasons. Rabbi Jakobovits writes that, “towards the end of the last century, a Catholic medical moralist still forbade the use of chloroform at normal births because it might endanger the mother and the child…” Jakobovits then praises Judaism for being above any such considerations."

The authors are suggesting, that halachically speaking, we need to reconsider our use of drugs in labor because they may be dangerous.  They make this suggestion as if it can be assumed that drugs in labor are inherently dangerous, but they do not have evidence to back up this claim.  In fact, every treatment used in labor is subjected to controlled clinical trials and years of experience that have attested to their safety and efficacy.  It is far far beyond the scope of this blog to review every pain treatment and its' specific risk/benefit profile. However, we have established that in Judaism, treating pain in labor is an honorable and appropriate goal. Every woman is not religiously obligated to suffer to atone for Eve's sin.

A fascinating exchange about this topic took place in Montreal Canada in 1849, shortly after the discovery of anesthesia.  An article about this debate was published in the Journal of the American College of Obstetrics and Gynecology, also known as ACOG.  The Journal is called "Obstetrics and Gynecology", and in volume 88 No. 5, November 1996, pages 895-898, Dr Jack Cohen writes of the debate that took place in Montreal between Dr James Simpson and Rabbi Avraham De Sola.  Rabbi De Sola was the first rabbi in Canada, and he was the new young Rabbi of Montreal's oldest congregation, the Spanish Portugese synagogue - Shearith Israel.

Dr Simpson had argued against the use of anesthesia for women in labor based on Genesis 3:16, the verse declaring that "B'etsev Tayldi Banim".  By using his knowledge of Hebrew, and the Jewish commentators (primarily the Radak), Rabbi De Sola boldly took on the Christian interpretation of the verse and shows how the word "B'Etsev" refers to the uterine contractions of labor and not the pain experienced by the woman in labor.  Interestingly, Rabbi De Sola went on to become a Professor of Hebrew Language at McGill University in Montreal.

The poskim in the almost 175 years that have passed since Rabbi De Sola's debate have almost universally understood and acknowledged the importance of treating the pain of labor.  It is accepted that we must treat a woman's labor pain the same way we would treat all pain and suffering for every person.

This is true even though every treatment has some level of risk. When risk is balanced against benefit, halachah has determined that since these treatments are overwhelmingly safe and effective when administered by trained professionals, they are halachically desirable, not just permitted. Furthermore, every patient has the opportunity to choose whether or not to avail themselves of these treatments, and each person can evaluate the risks of benefits of each medication before deciding whether or not she desires to use it.

In their conclusion, the authors clarify their case, and they cite some "evidence" to back their claims:

"To begin with the third example, the dangers of drugs during pregnancy, including obstetric analgesia and anesthesia, are well documented today. In fact, they have been well documented since at least the 1980s. Both the mother and child can suffer side effects ranging from sluggishness to brain damage and death. The fact that no Jewish authority has restricted or discouraged the use of drugs during labor may not be an occasion for self-congratulation; it may call for some serious halakhic soul-searching."

As sources for their assertion that obstetric analgesia and anesthesia drugs are dangerous, they quote two articles from 1981 (see their footnote #24).  If one carefully examines the sources used to support this article's assertions, and the general tone of the article itself, one is struck by impression that the authors are reflecting a worldview that views modern medicine, and especially obstetric medicine, with an extreme amount of suspicion. I suspect that arguments like these will go on forever, as they are not amenable to resolution by providing evidence to support one point of view over the other. For example, one of the sources cited was titled "Malepractice: How Doctors Manipulate Women".  If someone believes that doctors are guilty of intentionally manipulating their patients, then it will be very difficult, in fact almost impossible, to convince him/her by quoting evidence from the medical literature.

I hope that I at least provided some information for those people who are open minded enough to look upon their physicians, midwives, nurses and other appropriate caregivers as their allies instead of their enemies.  I totally agree with the authors of the article that we should never engage in self congratulation.  However, the fact that "no Jewish authority has restricted or discouraged the use of drugs during labor..." does not reflect a lack of "serious halakhic soul-searching", as the authors declare.  Rather, it reflects centuries of serious halachic concern for the comfort and well-being of women in labor.

I do owe you one more brief post on this topic regarding the safety of home births, and then we can move on to our next topic.

My oh my, How Times Have Changed

We have now described the fundamental assumption upon which the article "Obstetrics and the Curse of Eve" is based.  According to the authors, a birthing woman is in a category not exactly equal in halachic status to the critically ill patient. Thus, in what they consider to be the classical halacha; on Shabbat one must use a shinuy whenever possible, prior to the final stage of labor one may do nothing other than to call the midwife, and generally speaking only the midwife is called upon to violate Shabbat restrictions.

From here they go on to describe how much things have "changed".  Here are the next few paragraphs:

"Such halakhot could be easily implemented in a society where midwife attended home births were the rule. The only person who, under normal circumstances, had to transgress the Sabbath was the midwife. From a global perspective, home birth is still the norm and hospital birth the alternative. In middle- and high-income countries the opposite is true: the home birth rate in these countries is very low, for example, less than 1 percent in the United States. Where hospital births are the norm, the traditional halakhot about Sabbath observance have quickly become inoperative. 

Even a brief examination of a respected 1979 halakhic compendium will show how much these laws have changed. According to Rabbi Joshua Neuwirth, a woman should travel to the hospital at the onset of the slightest sign of labor. She may carry her possessions with her to the hospital, even through an area without a permitting enclosure (‘eruv) and can be accompanied by an “escort” (presumably her husband), who may also transgress the Sabbath. She may even, under certain circumstances, travel home from the hospital on the Sabbath if in fact she had been mistaken about being in labor.

What sources does Rabbi Neuwirth quote when allowing wholesale transgression of the Sabbath before the final stages of labor? Almost invariably he says, “So I have heard from rabbinic authorities” or refers his readers to the general rule of life-threatening situations (piqquaḥ nefesh). There is no attempt to justify these radical changes; piqquaḥ nefesh apparently speaks for itself."

We have already demonstrated that the fundamental assumption made by the athors is deeply flawed.  That is because the majority of the poskim follow the simple meaning of the words of the Shulhan Arukh and the rambam and the Gemara that state unequivocally that a birthing woman is "B'sakanat nefashot", and that the same laws that apply to any critical patient apply to her as well.  The Maggid Mishna that was quoted by the authors which differentiated between a birthing woman and a critically ill patient was either not accepted by many poskim, or interpreted by the poskim to be refering only to things being done l'yashev da'atah - to calm her fears.

R' Neuwirth, in Shemirat Shabbat K'Hilchatah (SSKH), paskens exactly NOT like the authors of the article would have you assume is the accepted halacha.  In fact, he paskens exactly like many of the poskim we quoted before, and that there is no halachic difference whatsoever between a birthing woman and a critically ill patient.  See SSKH Vol 1, 34:4 note 6 where he states, and I quote:

"see earlier in 32:28 (where R' Neuwirth paskens that one must use a shinuy for every critically ill patient whenever possible), therefore, the law of a birthing woman is the same as the laws of a critically ill patient, in that whenever it is possible, a shinuy must be used."

It is unclear why in the text of the SSKH R' Neuwirth quotes the Maggid Mishna when he states that the pain of birthing is a natural process. However, he provides the source in his note and refers us to the Arukh Hashulkhan and the Mishna Berura.  It is well known that the normal style of the SSKH is to leave this type of detailed analysis to the reader, and simply to provide the sources for someone interested in further investigation.  Regardless, the SSKH is crystal clear, both in 32:28 when he discusses the laws of the critically ill patient, and in 36:4 when he discusses the laws of the birthing woman, that he considers them exactly the same.  He thus follows, not surprisingly at all, the pattern of most poskim throughout the centuries, who did not differentiate between the two.  Unlike the authors who would have you believe that "medieval halakhic codes made a clear distinction between the birthing woman and the standard critically ill patient".

Thus it should be no surprise at all when he allows what the authors consider "wholesale transgression of the Sabbath".  He doesn't need any more sources, as the poskim, especially the Arukh HaShulkhan who WAS quoted by the SSKH, made abundantly clear that even things that are only needed to calm her down, but aren't medically necessary, are permitted on the Shabbat.

The next issue that the authors discuss is the use of male birth attendants.  In summary, they contend that Halakhah in general "severely limited the access of male physicians to women". Traditionally, births were attended by women only, and midwives were the attendents at births.  However, "today most Orthodox women standardly have their babies delivered by male physicians...", and this has been supported by the halachic authorities.  Consistent with the theme of their article, the assumption is made that the reason for this leniency of the modern poskim is that when life is in danger, we can allow transgressions of halachah, including the use of male birth attendants.  In their words, "The male physician is exempted from this rule (the rule prohibiting males from being present at the birth), presumably for reasons of piqquaḥ nefesh."

I will discuss this issue in detail in my next post.